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V/ 


ATLAS  AND  ABSTRACT 


OF   THE 


Diseases  of  the  Larynx 


BY 

DR.   L.   GRUNWALD 

of  Munich 


AUTHORIZED   TRANSLATION    FROM    THE   GERMAN 


EDITED    BY 


CHARLES   P.  GRAYSON,  M.  D. 

Lecturer  on  Laryngology  and  Rhinology  in  the  University  of  Pennsylvania- 

Physician-in-Charge  of  the  Throat  and  Nose  Department, 

Hospital  of  the  University  of  Pennsylvania 


With    toy    Colored    Figures   on    44    Plates 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS   Si    COMPANY 

1902 


Copyright,  1898,  by  W.  B.  Saunders. 


Reprinted  September,  1900,  and  November,  1902 


PREFACE. 


In  the  preparation  of  this  little  Atlas  of  the  Diseases 
of  the  Larynx  the  author  has  adopted  the  same  plan  as 
that  pursued  in  his  earlier  Atlas  of  the  Diseases  of  the 
Nose  and  Throat.  Its  object  is  to  help  the  beginner  in 
the  art  of  observing  and  interpreting.  As,  however,  a 
knowledge  of  the  previous  history  of  the  disease  and 
the  examination  of  contiguous,  as  well  as  of  more  distant 
organs  are  indispensable  for  diagnosis,  especially  in  this 
region,  each  picture  is  accompanied  by  the  necessary  data 
in  the  form  of  a  short  history. 

By  adopting  this  method  the  author  believes  he  has 
also  presented  a  valuable  aid  to  the  physician  who  has 
few  opportunities  of  seeing  diseases  of  the  larynx  and 
yet  wishes  to  be  able  to  recognize  them.  At  the  same 
time  a  clearer  mental  image  is  obtained  which  may  com- 
pensate for  possible  imperfections  in  the  actual  picture. 

The  illustrations  are  arranged  solely  according  to  ex- 
ternal appearances,  without  regard  to  the  nature  of  the 
disease;  partly  in  order  to  train  the  eye  by  comparing 
conditions  similar  in  appearance,  though  differing  widely 
in  their  true  nature,  and  partly  to  make  it  easier  to  find 
the  illustrations  which  most  resemble  the  particular  case 

3 


4  PREFACE. 

to  be  diagnosed.  Many  well-known  pictures,  as,  for 
instance,  that  of  diphtheria,  are  therefore  omitted. 

To  prepare  the  student  for  this  course  in  the  theory 
and  practice  of  diagnosis  a  short,  systematic  abstract  has 
been  added. 

In  the  author's  opinion,  a  knowledge  of  the  histology 
of  morbid  processes  is  most  essential  to  a  proper  under- 
standing of  them.  Twelve  plates  showing  the  most  im- 
portant elementary  alterations  have  accordingly  been 
devoted  to  this  purpose.  This  department  of  pathology, 
which  has  been  somewhat  neglected  in  the  text-books, 
affords  the  best  means  of  arriving  at  clear,  definite  ideas. 

Figure  1  is  taken  from  Luschka's  work  on  anatomy, 

two  illustrations  of  cadavers  from  the  well-known  atlas 

by  Bollinger.     All  the  other  illustrations  were  prepared 

by  the  (academic)  painter  Mr.  Keilitz,  from  sketches  or 

preparations  by  the  author,  who  takes  this  opportunity 

of  expressing  his   thanks   for   the   care   and   skill  with 

which  they  were  executed. 

The  Author. 


EDITOR'S  PREFACE. 


If  it  be  true  that  "good  wine  needs  no  bush,"  ^.tis 
certainly  true  that  so  good  a  book  as  this  needs  no 
preface.  The  American  editor  only  ventures  to  add 
a  few  words  relative  to  the  method  of  instruction  adopted 
in  this  book.  It  exemplifies  a  happy  blending  of  the 
didactic  and  clinical  such  as  is  scarcely  to  be  found  in 
any  other  volume  upon  this  subject  with  which  we  are 
acquainted.  It  is  upon  the  value  of  the  clinical  portion 
of  the  work  that  the  editor  would  dwell  with  particular 
emphasis.  The  beginner  will  find  here  a  series  of  patho- 
logical conditions,  illustrated  with  a  remarkable  fidelity 
to  Nature,  that  it  would  undoubtedly  require  him  a 
number  of  years  to  duplicate  in  actual  practice ;  while 
the  veteran,  however  rich  his  experience,  will  note  a 
precision,  a  finesse  in  diagnosis  that  cannot  fail  to  be 
instructive  and,  perhaps,  even  inspiring.  The  admirable 
translation,  which  is  the  work  of  Mr.  R.  Max  Goepp, 
has  been  carefully  compared  with  the  original,  and  the 
editor's  comments  are  intended  as  expository  of,  rather 

than  as  actual  additions  to,  the  text. 

C.  P.  G. 

5 


CONTENTS. 


PAGE 

Introductory  Eemarks  on  the  Anatomy  and  Physiology  of 

THE  Larynx 9 

Methods  of  Examination 19 

1.  Indirect  Laryngoscopy 19 

2.  Direct  Laryngoscopy 24 

3.  Inspection 25 

4.  Palpation 25 

5.  Auscultation        26 

Practical  Hints  for  the  Examination 28 

General  Eemarks  on  the  Causes  and  Treatment  of  Diseases 

of  the  Larynx .31 

Pathology  and  Treatment. 

I.  Acute  Inflammations 36 

1.  Superficial 36 

2.  Exudative 39 

3.  Interstitial 44 

4.  Inflammations  of  the  Muscles        48 

5.  Inflammations  of  the  Joints 49 

6.  Inflammations  of  the  Perichondrium 51 

7.  Symptomatic  (complicated)  forms  of  Acute  Inflamma- 

tions      54 

n.  Chronic  Inflammations 59 

1.  Superficial 59 

2.  Submucous 62 

3.  Inflammations  of  the  Muscles 63 

4.  Inflammations  of  the  Joints 63 

5.  Inflammations  of  the  Perichondrium  and  Cartilages  .    .  64 

6.  Complicated  Forms 64 

(a)  Tertiary  Syphilis 64 

(&)  Tuberculosis 68 

(c)   Leprosy 74 

{d)  Sclerosis 74 

(e)  Gout  and  Arthritis  Deformans 75 

7 


CONTENTS. 

PAGE 

III.  Neoplasms 75 

1.  HomologQus 75 

(a)  Neoplasms  of  Individual  Tissues 75 

(6)  Hyperplasias 77 

2.  Heterologous 81 

IV.  Disturbances  of  Motility 86 

1.  Mechanical 86 

2.  Neuroses 88 

(a)  Hyperkinetic 88 

(6)  Hypokinetic 90 

(c)   Parakiuetic 94 

V.  Disturbances  of  Sensibility 96 

V*.  Complicated  (functional)  Motor  and  Sensory  Disturb- 
ances     97 

YI.  Disturbances  of  the  Circulation 100 

VII.  Solutions  of  Continuity •  100 

VIII.  Foreign  Bodies 102 

IX.  Malformations 102 


LIST  OF  ILLUSTRATIONS. 


MACROSCOPIC  PLATES. 


Plates  1-3.       Various  Laryngoscopic  Images. 

Plates  4-7.       Alterations  of  the  Epiglottis. 

Plates  8-16.     Diseases  of  the  Vocal  Cords. 

Plate  17.  Subcordal  Alterations. 

Plate  18.  Disease  of  the  Ventricular  Bands. 

Plates  19-26.  Disease  of  the  Posterior  Wall. 

Plate  27.  Alterations  at  the  Superior  Aperture  of  the  Larynx. 

Plates  28-30.  Diffuse  Alterations. 


Plate  31,  32,  and  Fig.  15. 
Figs.  16-23.      Paralyses. 


Alterations  at  the  Superior  Aperture  of  the 
Larynx. 


MICROSCOPIC  PLATES. 

Plates  33-36.  Alterations  in  the  Epithelium. 

Plate  37.  Sarcoma  and  Carcinoma. 

Plate  38.  Alterations  of  the  Lymphatic  Apparatus. 

Plate  39.  Cysts  and  Angioma. 

Plate  40.  Disease  of  the  Blood-vessels. 

Plate  41.  Syphilitic  Tumors. 

Plate  42.  Fig.  1,  Syphilitic  Ulcer  ;  Fig.  2,  Tuberculosis. 

Plates  43-45.  Tuberculosis. 


Sagittal  Section  of  the  Neck 

29.  Thyroid  cartilage. 

31.  Cricoid  cartilage. 

32.  F.piglottis. 

33.  Ventricular  band. 

34.  Vocal  cord. 

38.  Arytenoid  cartilage. 

39.  Trachea. 

40.  Esoi)hagus. 


INTRODUCTORY    REMARKS 


ON    THE 


ANATOMY  AND  PHYSIOLOGY  OF  THE 

LARYNX. 


Both  form  and  functions  of  the  larynx  are  based  on 
its  skeleton.  This  is  built  up  mainly  on  two  large  cartil- 
ages, the  thyroid  and  the  cricoid.  Assuming  that  their 
shape  and  smaller  solid  portions  are  sufficiently  well 
known  from  general  anatomy,  we  proceed  at  once  to  a 
description  of  their  topographical  relations.  The  two 
broad  alse  of  the  thyroid  embrace  the  lateral  plates  of  the 
cricoid  which  are  narrower  in  front  than  behind,  while 
the  anterior  border  or  curvature  of  the  cricoid  is  thrust 
forward  under  the  thyroid.  Between  this  anterior  border 
of  the  cricoid  and  the  lower  part  of  the  thyroid  an  inter- 
val filled  with  soft  structures  can  easily  be  felt  in  the  liv- 
ing subject.  Above  and  at  the  sides,  parts  of  the  thyroid 
only  can  be  felt :  the  lateral  plates  (alse)  and  the  cornua. 
In  front,  the  upper  border  of  the  thyroid  cartilage  pro- 
jects sharply  forward,  and,  with  its  notch  which  can  be 
plainly  felt,  especially  in  men,  forms  the  prominence  in 
the  throat  known  as  Adam's  apple ;  the  latter  is  also 
occasionally  visible  in  the  more  vigorous  of  the  daughters 
of  Eve.  The  true  base  of  the  entire  structure  is  there- 
fore the  cricoid  cartilage,  which  also  supports  the  smaller 
ones :  the  arytenoid,  Santorini's,  and  the  cuneiform  car- 
tilages. The  latter  are  called  cartilages  of  motion,  to  dis- 
tinguish them  from  the  supporting  cartilages. 

The  arytenoid  cartilages  articulate  with  the  upper  bor- 

9 


10  DISEASES  OF  THE  LARYNX. 

(ler  of  the  cricoid  by  two  symmetrical  articular  facets  in 
such  a  manner  that,  seen  from  above  in  a  resting  position, 
they  present  a  triangular  cross-section,  one  leg  looking 
forward  and  inward  (toward  the  median  line),  one  back- 
ward and  inward,  and  the  wide  sweep  of  the  hypotenuse 
forward  and  outward.  The  joint  itself  is  in  the  form  of 
a  saddle,  having  one  side  directed  forward  and  inward, 
the  other  backward  and  outward. 

Above,  the  concave  surface  of  each  arytenoid  cartilage 
presents  a  process  on  which  rests  the  small,  horn-shaped 
cartilage  of  Santorini  (corniculum  laryngis),  while  at  the 
sides  the  cuneiform,  or  AVrisberg's,  cartilages  form  another 
link  in  the  cartilaginous  chain  surrounding  the  upper 
border  of  the  cricoid. 

In  front,  this  chain  finds  a  point  of  attachment  in  the 
epiglottis  which  resists  pressure  in  both  directions,  its 
principal  movement  being  backward  and  forward. 

All  of  these  solid  parts  are  bound  together  by  a  con- 
tinuous sheet  of  elastic  connective  tissue,  which  becomes 
thi(5kened  to  form  cords  and  ligaments  wherever  there  is 
increased  active  or  passive  strain.  Of  these  ligaments 
(the  names  and  form  of  which  we  again  assume  to  be 
known),  the  cricothyroid  membrane  can  be  felt  from  the 
outside.  We  may  consider  the  structures  known  as  the 
true  vocal  cords  and  the  ventricular  bands,  or  false  vocal 
cords,  to  be  folds  of  the  connective  tissue  which  respond 
to  the  pull  of  the  moveable  cartilages. 

The  larynx  is  connected  with  the  surrounding  struc- 
tures partly  by  ligaments  and  partly  by  muscles.  It  forms 
the  beginning  of  the  air-passage,  and  is  attached  to  the 
hyoid  bone  by  means  of  the  thyrohyoid  ligaments,  the 
middle  one  of  which,  with  its  overlying  muscle,  can  be 
felt  in  the  living  subject;  posteriorly  it  is  held  in  position 
by  the  hiryngeal  and  pharyngeal  muscles.  The  latter, 
assisted  by  the  thyrohyoid  muscles,  elevate  the  larynx  or 
one  side  of  it,  while  the  sternothyroid  muscle  depresses 
it  and,  by  virtue  of  its  insertion  in  the  lower  back  part 
of  the  thyroid  cartilage,  tends  to  rotate  it  about  the  crico- 


ANATOMY  AND  PHYSIOLOGY.  11 

thyroid  articulation  as  a  pivot,  depressing  it  behind  and 
elevating  it  in  front. 

Below,  the  larynx  is  connected  with  the  trachea  by  the 
cricotrachean  membrane. 

The  posterior  surface  of  the  larynx  (formed  by  the 
posterior  half  of  the  cricoid  cartilage  and  the  upper  border 
of  the  epiglottis)  corresponds  to  the  anterior  surface  of 
the  esophagus,  and  may  therefore  be  regarded  as  belong- 
ing either  to  the  lowest  division  of  the  pharynx  or  to  the 
upper  division  of  the  esophagus.  In  a  sense  the  posterior 
and  also  the  lateral  walls  of  the  larynx  are  free  and  pro- 
ject into  the  lumen  of  the  pharynx.  Thus  the  larynx, 
by  pushing  out  a  semicircular  fold  of  the  mucous  mem- 
brane of  the  esophagus,  narrows  the  lumen  of  that  tube 
so  that  it  almost  disappears  in  the  median  line  at  this 
point  and  is  forced  to  find  room  on  the  sides,  where  the 
soft  parts  offer  less  resistance  than  the  rigid  spinal  column. 
This  results  in  the  formation  of  lateral  extensions  known 
as  sinus  pyriformes  (pirus,  a  pear),  which  can  be  seen  in 
the  living  subject  with  the  laryngoscope,  although  in  the 
resting  position  they  are  flattened  out  by  the  pressure  of 
the  adjacent  soft  parts. 

In  front,  the  larynx  is  covered  by  the  muscles  already 
described,  and  more  superficially  by  the  sternohyoid 
muscle  and  the  cervical  fascia. 

The  anterior  border  of  the  cricoid  cartilage  also  gives 
attachment  to  the  thyroid  fascia.  Occasionally  a  third 
lobe  of  the  thyroid  gland,  known  as  the  pyramidal  lobe, 
extends  upward  in  front  of  the  cricoid  cartilage,  while 
the  lateral  plates  are  partially  covered  by  the  two  prin- 
cipal lobes  of  the  gland. 

It  should  be  remembered  that  of  the  many  lymph- 
glands  in  the  neck  one,  a  small  one,  lies  in  front  of  the 
larynx,  immediately  in  front  of  the  cricothyroid  mem- 
brane. The  lymph-channels  of  the  organ  empty  into  the 
submaxillary  and  cervical  lymphatic  glands. 

Besides  the  muscles  already  mentioned  there  is  a  series 
of  smaller  ones  to  afford  movement  of  the  several  cartil- 


12  DISEASES  OF  THE  LARYNX. 

ages  on  each  other — the  intrinsic  muscles.  It  will  be 
best  to  consider  them  in  connection  with  their  individual 
actions. 

The  lateral  and  posterior  crico-arytenoid  muscles  are 
inserted  into  tlie  outer  angle  of  the  base  of  the  arytenoid 
cartilages ;  therefore  known  as  the  muscular  process.  The 
lateral  portions  arise  by  a  fan-shaped  origin  from  the 
sides  of  the  arytenoid  cartilages  externally ;  the  posterior, 
on  the  other  hand,  have  their  broad  origin  on  the  posterior 
surfice  of  the  same  cartilage.  The  posterior  muscles  em- 
brace the  posterior  and  lateral  portions  of  the  muscular 
processes ;  the  lateral  muscles  only  the  lateral.  As  the 
center  of  the  arytenoid  cartilage  must  form  the  pivot,  the 
action  of  these  muscles  is  clear.  The  lateral  crico-aryte- 
noid muscles  draw  the  muscular  process  forward  and  out- 
ward, so  that  the  vocal  process  (anterior  angle  of  the  base 
of  the  arytenoid  cartilage)  moves  inward  and  backward ; 
the  posterior  crico-arytenoid  nmscles  have  a  directly  an- 
tagonistic action.  As  the  true  vocal  cords  are  attached  to 
the  vocal  process,  they  necessarily  follow  these  move- 
ments, and  the  muscles  are  therefore  known  respectively 
as  the  adductors  and  abductors  of  the  true  vocal  cords. 

The  transverse  arytenoid  muscle  passes  transversely 
across  between  the  two  arytenoid  cartilages  in  the  middle 
line,  and  by  its  contraction  effects  mesial  approximation 
of  the  two  cartilages.  When  these  muscles,  assisted  by 
the  lateral  crico-arytcMioid  muscles,  are  put  on  the  stretch 
they  effectually  fix  the  arytenoid  cartilages,  so  that  the 
latter  afford  a  fixed  origin  to  another  muscle,  the  thyro- 
arytenoid, which  again  consists  of  two  fasciculi,  the  infe- 
rior or  internal  and  superior  or  external.  The  inferior 
thyro-arytenoid  muscle  lies  within  the  membranous  fold 
known  as  the  true  vocal  cord  (and  parallel  with  it),  the 
suj)eri<)r  within  the  fold  known  as  tlie  ventricular  band  ; 
botli  are  inserted  into  tlie  lower  half  of  the  thyroid  cartil- 
age at  the  line  of  junction  of  the  two  alae.  The  action  of 
the  muscles  is,  therefore,  to  ])ut  these  folds  on  tlie  stretch 
whenever  botii  their  anterior  and  posterior  points  of  attach- 


ANATOMY  AND  PHYSIOLOGY.  13 

ment  become  fixed  so  that  they  cannot  approach  each 
other.  In  order  to  fix  the  posterior  origin^  it  is  further 
necessary  that  the  arytenoid  cartilage  be  fixed  to  the  cri- 
coid by  means  of  the  mechanism  already  described. 

The  thyroid  and  cricoid  cartilages  move  against  each 
other  by  means  of  the  cricothyroid  articulation.  As  this 
is  placed  rather  far  back,  the  upper  anterior  border  of  the 
thyroid  traverses  the  greater  distance  at  each  excursion. 
(It  is  immaterial  whether  the  lower  border  of  the  thyroid 
is  drawn  toward  the  upper  border  of  the  cricoid  or  the 
contrary  takes  place.)  Approximation  is  effected  by  con- 
traction of  the  cricothyroid  muscle,  while  the  action  of 
the  sternothyroid,  as  stated  above,  is  directly  antagonistic. 
In  order  to  stretch  the  folds  of  membrane  attached  to  the 
cartilages  these  two  muscles  must  act  together,  for,  if  the 
cricothyroid  muscle  alone  were  contracted,  the  cricoid 
cartilage  would  simply  follow  the  pull  of  that  muscle ; 
while  if  the  sternothyroid  alone  were  contracted,  the 
same  would  be  true  of  the  thyroid  cartilage. 

It  follows,  therefore,  that  passive  stretching  or  tension 
of  the  true  vocal  cords  can  take  place  only 

(1)  When  the  arytenoid  cartilages  are  fixed  to  the  cri- 
coid cartilage ; 

(2)  When  the  cricoid  cartilage  is  drawn  backward  and 
the  thyroid  forward. 

To  eifect  this  the  following  muscles  are  required  : 

(1)  The  lateral  crico-arytenoid,  or  the  transverse  ary- 
tenoid muscles,  or  these  two  groups  together; 

(2)  The  cricothyroid  and  the  sternothyroid  muscles. 
We  should  observe,  at  the  outset,  that  the  action  of  the 

true  vocal  cords  consists  not  only  in  passive  tension,  which 
must  necessarily  accompany  reduction  in  width,  but  also 
in  active  contraction,  which  results  in  increased  vndth,  both 
actions  being  required  to  give  them  the  elasticity  necessary 
for  voice-production.  The  latter  is  accomplished  by  con- 
traction of  the  inferior  thyro-arytenoid  muscles,  which  are 
able  to  act  as  soon  as  their  origin  and  insertion  are  fixed 
in  the  manner  just  described. 


14 


DISEASES  OF  THE  LARYNX. 


In  like  manner  the  superior  thyro-arytenoid  muscles 
contract  the  ventricular  bands  within  which  they  are  en- 
closed ;  this  hajipens  regularly  in  swallowing,  but  only 
exceptionally  in  speaking. 

The  actions  of  the  several  muscles  will  be  better  under- 
stood by  the  aid  of  the  following  diagram  : 


(^ 

m 

ct'       1 

Id 

J( 

^^a»**^'^*^ii«ssiii^^ 

ct 

St 

Fig.  2. 

A 


8y  thyroid  cartilage,  Aj  cricoid  cartilage,  both  cut  in  a 
mesial  sagittal  plane.  6r,  arytenoid  cartilage,  c^,  direction 
of  pull  of  the  cricothyroid  muscle.  Action  :  a})proxima- 
tion  of  anterior  inferior  margin  of  thyroid,  and  upper 
border  of  cricoid  cartilages,  ct',  direction  in  which  the 
upper  border  of  the  thyroid  is  at  the  same  time  tilted  for- 
ward. 

sf,  direction  of  pull  of  the  sternothyroid  muscle. 
Action  :  to  depress  tlie  cricoid  caTtilage.  .s-^,  direction  in 
which  the  upper  border  of  the  cricoid  is  at  the  same  time 
tilted  backward. 

tai,  direction  of  ])idl  of  the  inferior  thyro-arytenoid. 

Scliema  (Fig.  3)  of  the  action  of  muscles  on  the  arytenoid 
cartilage  and  on  the  true  vocal  cords.  Both  parts  in  hori- 
zontal section  and  in  respiratory  position.  The  cords  are 
seen  to  consist  of  a  ligamentous,  and  a  cartilaginous  por- 
tion {/d  and  ^jc).    According  to  their  respective  functions, 


ANATOMY  AND  PHYSIOLOGY. 


15 


the  middle  part  of  the  cartilage  is  called  the  vocal  process, 
the  lateral  portion  the  muscular  process  (jw  andpwt). 


Fig.  3. 


/,  direction  of  the  contraction  of  the  inferior  thyro-ary- 
tenoid  muscles.  Action  :  tension  of  the  edges  of  the  true 
vocal  cords. 


cl,  direction  of  pull  of  the  lateral  crico-arytenoid  muscles. 
Action  :  rotation  of  arytenoid  cartilage  about  the  articu- 
lation which  is  in  the  centre ;  adduction  of  the  true  vocal 
cords. 

p  (Fig.  3),  direction  of  pull  of  the  posterior  crico-aryte- 


noid muscles.     Action :  rotation   in  opposite  directions ; 
abduction  of  the  true  vocal  cords. 


16  DISEASES  OE  THE  LARYNX. 

t  (Fig.  3),  direction  of  pull  of  the  transverse  arytenoid 
muscle.  Action  :  horizontal  approximation  of  arytenoid 
cartilages  without  rotation. 


Schema  of  the  combined  action  of  the  adductor  and 
transverse  arytenoid  muscles  :  rotation  inward  of  aryte- 
noid cartilages  until  the  vocal  processes  come  in  contact 
with  each  other  and  even  the  posterior  portions  of  the 
cartilages  are  approximated,  resulting  in  closure  of  the 
glottis  cartilaginea.  The  glottis  ligamentosa  is  still  open. 
Closure  of  the  latter  is  accomplished  only  by  the  codper- 
ation  of  the  internal  thyro-arytenoid  muscles  (see  Fig.  7). 

The  inner  edges  of  the  cords  still  present  a  wavy  out- 
line ;  that  is,  they  are  slack,  for  they  cannot  be  stretched 
taut  until  both  points  of  attachment  are  fixed  in  opposite 
directions.  Fixation  of  the  posterior  point  (arytenoid 
cartikige)  has  already  been  effected  by  the  action  of  the 


Fig.  7. 

above  muscles  ;  to  fix  the  anterior  jioint  (thyroid  cartilage) 
the  cricothyroid  muscle  must  be  contracted.  Both  parts 
of  the  glottis  are  now  seen  to  be  closed  and  the  true  vocal 
(;ords  are  taut  (Fig.  8). 

The  movements  of  the  arytenoid  cartilages  in  the  ])er- 
pendicular  plane  are  not  important  for  a  study  of  their 


ANATOMY  AND  PHYSIOLOGY.  17 

function.  These  movements  result  from  the  irregular 
curve  of  the  crico-arytenoid  articulation,  which  is  highest 
at  the  center  and  slopes  away  outward  and  backward,  and 
inward  and  forward,  so  that  the  apices  of  the  cartilages 
are  brought  into  higher  or  lower  planes  during  motion. 


The  covering  of  the  larynx  consists  of  mucous  mem- 
brane of  varying  thickness,  containing  acinous  glands, 
found  chiefly  where  the  submucosa  is  thick  and  loosely 
attached  to  the  underlying  tissue.  They  are  especially 
numerous  about  the  upper  margin  of  the  posterior  surface 
of  the  larynx,  in  the  ventricular  bands,  and  in  the  ventri- 
cles— in  fact,  in  all  those  parts  which  are  most  concerned 
in  deglutition  and  phonation.  The  mucous  membrane  is 
closely  adherent  to  the  free  edges  of  the  true  vocal  cords, 
whereby  it  is  enabled  to  take  part  in  their  vibrations. 
Here  and  on  the  under  surface  the  mucous  membrane 
forms  thin  strips,  running  for  the  most  part  in  the  sagittal 
plane,  in  some  places  forming  a  network  which,  in  vertical 
transverse  sections,  appears  as  papillae  (see  Plate  36, 
Fig.  3).  It  is  important  to  know  this  so  as  to  avoid  mis- 
taking these  structures  for  pathological  formations,  and 
also  because  they  explain  why  papillary  neoplasms  are  so 
apt  to  form  in  this  situation.  Their  similarity  to  the 
papillae  of  the  skin  is  very  marked,  and  the  propensity  of 
both  varieties  to  form  horny  epithelial  warts  is  therefore 
readily  understood. 

In  the  epiglottis  we  also  find  true  lymph-follicles, 
which  we  must  be  careful  not  to  confound  with  miliary 
tubercles,  if  they  are  at  all  well  developed. 

2 


18  DISEASES  OF  THE  LARYNX. 

The  upper  layer  of  the  mucous  membrane  is  composed 
of  epithelium,  as  elsewhere.  On  the  parts  nearest  the 
fauces  it  consists  of  stratified  squamous  cells  in  layers  of 
varying  thickness.  Squamous  epithelium,  then,  is  found 
on  both  surfaces  of  the  epiglottis,  on  the  upper  surfaces 
of  the  aryepiglottidean  folds — in  short,  on  what  is  known 
as'  the  superior  aperture  of  the  larynx,  and  also  extends 
from  the  central  portion  of  the  arytenoid  cartilages  to  the 
true  vocal  cords.  On  the  edges  of  the  cords  the  mucous 
membrane  consists  of  a  smooth  layer  which  fills  up  the 
interstices ;  sometimes  it  follows  the  eles'ations  and  de- 
pressions, so  as  still  more  to  simulate  the  appearance  of 
papillary  neoplasms.  The  remaining  parts  of  the  mucous 
membrane  are  covered  with  the  characteristic  ciliated 
columnar  epithelium  of  the  air-passages. 

The  innervation  is  supplied  exclusively  by  the  pneumo- 
gastric.  One  branch,  the  superior  laryngeal  nerve,  is 
given  off  opposite  the  angle  of  the  jaw,  and  divides  above 
the  hyoid  bone  into  two  branches  :  the  external  laryngeal 
branch,  containing  motor  fibers,  which  descends  along  the 
side  of  the  thyroid  cartilage  to  supply  the  thyro-epiglot- 
tideus  and  cricothyroid  muscles ;  and  the  internal  laryn- 
geal branch,  which  pierces  the  thyrohyoid  membrane 
about  the  middle  of  the  upper  border  of  the  thyroid  car- 
tilage and  supplies  the  entire  mucous  membrane  of  the 
larynx  with  sensory  fibers. 

The  second  branch,  the  inferior  or  recurrent  laryngeal 
nerve,  follows  a  different  course  on  the  two  sides  of  the 
body.  The  right  recurrent  nerve  arises  at  the  level,  and 
in  front,  of  the  right  subclavian  artery,  around  which  it 
winds  from  before  backward,  ascends  between  the  trachea 
and  the  esophagus,  enters  the  larynx  at  the  lower  border  of 
the  cricoid  cartilage  and  distributes  its  fibers  to  the  muscles. 

The  left  recurrent  arises  at  the  level,  and  in  front,  of 
the  arch  of  the  aorta,  winds  around  this  structure,  also 
from  before  backward,  and  ascends  a  little  in  front  of  its 
fellow — that  is,  rather  beside  than  behind  the  trachea — to 
enter  the  larynx  in  the  same  way  as  the  right  recurrent. 


METHODS  OF  EXAMINATION.  19 

This  condition  explains  why  aneurysm  of  the  aorta 
preferably  affects  the  left,  and  cancer  of  the  esophagus 
the  right  recurrent  nerve. 

The  recurrent  laryngeal  nerves  supply  all  the  other 
muscles  of  the  larynx  (in  addition  to  those  already  men- 
tioned) ;  they  may  supply  the  thyro-epiglottideus  muscle 
instead  of  the  superior  laryngeal  nerves,  just  as  the  latter 
in  some  cases  supply  the  transverse  arytenoid  muscle  in- 
stead of  the  recurrent  laryngeal  nerves. 

The  fibers  of  the  recurrent  laryngeal  nerves  present 
some  differences  in  their  physiological  action,  some  su2)ply- 
ing  the  muscles  which  effect  closure  of  the  glottis  and 
stretching  of  the  true  vocal  cords,  while  others  supply 
the  dilators  of  the  glottis,  the  posterior  crico-arytenoid 
muscles.  In  lesions  of  the  nerve-trunk  the  latter  fibers 
suffer  first,  so  that  we  have  at  first  paralysis  of  the  ab- 
ductors and  secondarily  paralysis  of  the  adductors. 

The  sensibility  of  the  larynx  varies  in  different  situa- 
tions ;  it  is  greatest  in  the  interarytenoid  space ;  hence 
diseases  of  this  part  are  so  troublesome  on  account  of  the 
intense  pain  and  constant  irritation  and  desire  to  cough ; 
even  superficial  irritation  in  this  region  may  give  rise  to 
attacks  of  convulsive  cough  (see  Plate  18,  Fig.  2). 

The  center  which  presides  over  the  movements  of  the 
larynx  is  found,  at  least  in  animals,  at  the  base  of  the 
ascending  frontal  convolution.  From  this  point  the  fibers 
run  through  the  inner  capsule  to  the  medulla  oblongata. 
Systemic  diseases  involving  these  areas  must  therefore 
have  an  injurious  effect  on  the  action  of  the  larynx. 


METHODS  OF   EXAMINATION. 

(1)  INDIRECT    LARYNGOSCOPY   WITH    THE    MIRROR. 

The  laryngoscopic  image,  as  is  well  known,  is  inverted 
or,  in  reality,  only  half  inverted,  since  in  the  mirror 
which  is  held  at  an  angle  of  about  45  degrees  to  the  plane 


20 


DISEASES  OF  THE  LARYNX. 


of  the  aperture  of  the  larynx,  the  anterior  parts  appear 
above,  and  the  posterior  parts  below.  It  is  only  when 
the  image  is  represented  on  paper  that  it  appears  com- 
pletely inverted,  the  front  corresponding  to  the  back,  and 
vice  verna. 


U.s 


c.v. 


Fig.  9  shows  the  laryngoscopic  image  of  a  normal 
larynx  as  it  appears  on  paper,  the  movable  parts  in  the 
position  which  they  occupy  during  respiration.  It  also 
shows  the  anatomy  of  the   parts  in   the  living  subject. 

E.,  epiglottis  ;  in  the  middle  is  seen  its  posterior  surface, 
which  is  rolled  from  behind  forward  and  therefore  looks 
uj)ward  ;  on  each  side  the  surface  of  the  tongue  is  covered 
witli  blood-vessels.  This  is  always  taken  as  tlie  starting- 
])()int  in  laryngoscopy,  the  directions  being  given  accord- 
ing to  the  actual  relations  of  the  parts,  not  the  one  that 
apj)ears  in  the  image.  In  front  of  the  epiglottis  the  val- 
lecula ( V.)  extends  to  the  tongue,  Z.,  interrupted  at  its 
center  by  the  glosso-e])iglottidean  ligament,  Lg.e. 

The  posterior  margin  of  the  cavity  of  the  larynx 
begins  at  the  sides  witli  tlie  aryteno-epiglottidean  folds, 
Ld.c,  wliich  invest  the  cartilages  of  Wrisberg  and  Santo- 
rini.  The  arytenoid  cartilages  lie  hidden  beneath  them, 
and  between  these  cartilages  tlie  mucous  membrane  dips 
down  into  the  interarytcnoid  sj)ace.  For  the  sake  of 
brevity  in  describing  the  relations  of  parts,  we  speak  only 


METHODS  OF  EXAMINATION.  21 

of  the  arytenoid  cartilages,  ignoring  the  cuneiform,  which 
merely  follow  the  movements  of  the  former  passively. 

The  external  surface  of  the  posterior  wall  forms  the 
anterior  boundary  of  the  entrance  to  the  esophagus ;  at 
the  sides  the  latter  opens  into  the  sinus  pyriformes,  s.p. 

Within  the  larynx  the  glottis,  g,  extends  between  the 
true  vocal  cords,  c.v.,  the  ligamentous  portion,  p.L,  form- 
ing the  anterior  two  thirds,  the  cartilaginous  portion,  ^>.c., 
the  posterior  third  ;  the  lumen  of  the  glottis,  of  course, 
varies  with  the  position  of  the  vocal  cords. 

Above  the  true  vocal  cords  (whose  normal  color  is  a 
dull  yellowish-white)  lie  the  ventricular  bands,  ligamenta 
thyroidea  superiora,  l.t.s.,  their  under  surface  projecting 
into  the  ventricle  of  the  larynx,  v. J}!,  (ventricle  of  Mor- 
gagni). 

Marked  prominence  of  the  ventricular  bands  produces 
apparent  narrowing  of  the  true  vocal  cords  (Plate  3, 
Fig.  1). 


V.3L 


Fig.  10. 

If,  on  the  contrary,  they  recede  unduly,  the  interior  of 
the  ventricle,  v.3f.,  is  exposed.  The  anterior  surface  of 
the  cricoid  cartilage  can  also  be  seen  in  this  image,  and, 
through  the  glottis,  the  front  of  the  trachea  and  its  rings. 
If  the  glottis  is  opened  exceptionally  wide,  the  deepest 
parts  of  the  trachea  and  the  bifurcation  come  into  view 
(Plate  1,  Fig.  2) ;  sometimes  it  is  even  possible  to  look 
into  the  bronchi.  On  the  other  hand,  part  of  the  larynx 
is  sometimes  hidden,  especially  in  children,  in  whom  the 
epiglottis  is  frequently  curved  in  the  shape  of  an  i2,  so 
that  one  has  difficulty  in  seeing  the  true  vocal  cords  even 


22 


DISEASES  OF  THE  LARYNX. 


(Plate  2,  Fig.  1).  In  some  cases  the  larynx  may  be  so 
obliquely  placed — either  from  pathological  causes  or  as  an 
individual  peculiarity — that  it  partly  disappears  under  the 
epiglottis  (Plate  2,  Fig.  2);  in  others,  abnormal  growths 
may  cut  off  part  of  the  image  above  (Plate  2,  Fig.  3 ; 
Plate  16,  Fig.  1)  and  behind  (Fig.  15). 

Ordinarily  the  light  strikes  the  larynx  from  behind  ; 
but  in  Killian's  posture,  where  the  operator  applies  the 
mirror  from  below,  making  the  patient  bend  well  forward, 
the  image  is  taken  more  from  the  front.  Consequently 
more  is  seen  of  the  lingual  surface  of  the  epiglottis  and 
less  of  the  anterior  portions  of  the  true  vocal  cords ;  on 
the  other  hand,  their  posterior  attachment  can  be  plainly 
seen,  as  well  as  the  entire  front  of  the  cricoid  cartilage, 
but  no  part  of  its  posterior  surface  (Plate  1,  Fig.  1). 


p.e. 


Fig.  11. 

In  phonation  (Fig.  11)  the  epiglottis  is  raised  in  front, 
so  as  to  bring  the  petiolus,  p.e.,  into  view.  The  arytenoid 
cartilages  approach  each  other,  so  that  the  interarytenoid 
space  almost  disappears ;  the  true  and  the  false  vocal 
cords  also  approach  the  median  line  and  lie  in  so-called 
juxtaposition.  The  glottis  is  reduced  to  a  narrow,  spindle- 
shaped  chink  which  is  barely  visible,  the  posterior  ex- 
tremity coming  in  relation  with  the  vocal  processes.  This 
is  the  image  of  the  so-called  chest-voice. 

In  the  production  of  head  or  falsetto  notes  the  glottis  is 
even  more  tightly  closed  beliind,  but  gapes  wide  apart  in 


METHODS  OF  EXAMINATION. 


23 


front  (Figs.  12  and  13).  This  posterior  closure  reaches 
its  highest  degree  in  the  production  of  so-called  abdom- 
inal notes — ventriloquist's  voice  (Fig.  14),  in  which  the 
convulsive  contraction  of  the  adductors  may  even  result 


Fig.  12. 


Fig.  13. 


in  overlapping  of  the  true  vocal  cords  in  their  posterior 
half.  At  the  same  time  the  arytenoid  cartilages  are 
pressed  tightly  together,  and  the  true  vocal  cords  appear 
somewhat  narrower  on  account  of  the  projection  of  the 
inner  edges  of  the  ventricular  bands. 

If  for  any  mechanical  reason  the  true  vocal  cords  can- 
not be  stretched,  it  occasionally  happens  that  the  superior 
thyro-arytenoid  muscles  contract  violently  and  stretch  the 


ventricular  bands  to  such  a  degree  that  their  inner  edges 
are  thrown  into  vibration  by  the  air-current — resulting  in 
so-called  false  vocal- cord  phonation  ;  the  true  vocal  cords 
are,  of  course,  entirely  concealed. 


24  DISEASES  OF  THE  LARYNX. 

(2)  DIRECT    LARYNGOSCOPY. 

This  method  was  introduced  by  Kirstein,  and  has  the 
advantage  that  the  larynx  is  viewed  directly.  A  specially 
constructed,  grooved  compressor  is  used  to  press  the  tongue 
forward  and  exclude  it  from  the  field  of  vision,  the  patient 
holding  his  head  as  high  and  as  far  back  as  possible. 

When  the  method  can  be  used  at  all,  it  has  the  advan- 
tage of  showing  more  of  the  anterior  surface  of  the  pos- 
terior wall  than  is  the  case  with  the  mirror.  It  is  also 
free  from  the  objection  of  having  the  image  partly  ob- 
scured by  mucus  and  foreign  material,  a  factor  of  some 
importance  in  the  examination  of  children  and  uncon- 
scious patients ;  indeed,  for  the  latter  the  method  will 
probably  always  be  indispensable.  For  the  rest,  its  indi- 
cation and  its  application  are  still  in  the  experimental  stage. 

Whatever  method  of  examination  be  used,  reflected 
light  is  preferable  to  direct  light,  which  is  always  more  or 
less  cut  off  by  the  head  of  the  operator ;  we  therefore  use 
a  reflector  which  is  fastened  either  to  the  operator's  fore- 
head or  to  a  stand  constructed  for  the  purpose. 

Any  strong  light  will  do  for  the  source ;  the  choice  will 
therefore  depend  on  the  conveniences  at  hand.  One  dis- 
advantage which  is  common  to  all  is  the  color ;  it  is  least 
in  the  electric  arc  light  or  in  Auer's  gas-burner.^  The 
latter  was  used  for  all  the  laryngeal  images  illustrated  in 
this  work.  If  it  is  especially  desirable  to  obtain  the  nat- 
ural color  in  any  particular  case,  or  if,  in  general,  sunlight 
is  easily  obtainable,  it  will  be  found  to  be  decidedly  the 
best  light.  In  order,  however,  to  minimize  the  changes 
incident  to  the  diflerent  times  of  the  day,  and  at  the  same 
time  to  diminish  the  glare,  it  will  be  best  to  let  the  sun- 
light fall  first  on  a  large  reflector,  after  it  has  passed 
through  the  window^,  and  from  that  by  the  ordinary  re- 
flector into  the  larynx. 

^  [The  Welsbach  light,  the  mantle  being  pnre  white,  nsed  in  con- 
junction with  a  condensing  lens,  is  certainly  unexcelled,  if  not  nn- 
ecuialled,  in  its  color  and  illuminating  power,  by  any  other  artificial 
source  of  light. — Ed.] 


METHODS  OF  EXAMINATION.  25 

Laryngoscopy  is,  of  course,  the  principal  method  of 
examining  the  larynx,  as  it  gives  results  which  can  be 
studied  directly ;  still  we  must  not  entirely  neglect  other 
methods  whicli  formerly  constituted  the  only  means  of 
arriving  at  a  diagnosis  and  even  now  have  not  entirely 
lost  their  value.  We  refer  to  external  inspection,  'palpa- 
tion, and  auscultation  of  the  voice  and  possible  adventi- 
tious sounds. 

(3)  INSPECTION. 

By  inspection  we  note  unusual  shape^  and  especially 
displacement  of  the  larynx^  usually  due  to  lateral  pressure 
by  tumors  in  the  neck.  The  cartilages  are  sometimes  dis- 
placed far  to  one  side,  or  even  close  to  the  angle  of  the 
jaw,  the  line  connecting  the  upper  notch  of  the  thyroid 
with  the  center  of  the  lower  border  being  oblique  instead 
of  perpendicular. 

(4)  PALPATION. 

Palpation  informs  us  whether  the  two  halves  of  the 
thyroid  cartilage  are  symmetrical.  It  sometimes  happens 
— as  an  abnormality,  however — that  one  half  is  pushed 
back  under  the  other,  with  the  result  that,  instead  of  a 
well-defined  line  of  junction  in  front,  we  feel  two  surfaces 
meeting  the  median  line  of  the  neck  at  different  angles, 
one  overlapping  the  other,  so  that  the  finger  sinks  into  an 
obtuse  angle  facing  sideways. 

Irregularities  on  the  surfaces  of  the  cartilages  are 
more  significant,  the  surfaces  being  normally  smooth. 
Such  irregularities  may  indicate  a  perichondritic  or  a 
chondritic  process,  or  the  effects  of  one  ;  sometimes  tumors, 
especially  malignant  growths,  betray  their  presence  in  this 
way  :  here,  as  elsewhere,  cancer  often  manifests  itself  in 
prominent,  nodular,  dense  infiltrations.  If,  however,  a 
marked  condition  of  this  kind  be  felt  by  the  examiner,  he 
should  not  immediately  pronounce  the  tumor  a  malignant 
growth,  for  syphilitic  perichondritis  presents  a  very  simi- 
lar picture  ;  and  if  no  signs,  or,  at  least,  no  positive  signs, 
are  found   within  the  larynx,  it  will  be  advisable,  as  a 


26  DISEASES  OF  THE  LARYNX. 

matter  of  routine,  to  take  that  possibility  into  considera- 
tion. Miraculous  cures  are  sometimes  ef!*ected  by  such 
"  perfunctory  '^  reasoning  and  corresponding  line  of  treat- 
ment. 

Under  certain  conditions  palpation  may  play  a  promi- 
nent part  by  enabling  one  to  determine  paralyses  which 
could  not  otherwise  be  recognized.  In  total  paralysis  of 
the  recurrent  nerve,  or  at  least  in  complete  phonatory 
paralysis,  the  normal  vibration  of  the  thyroid  cartilage 
may  be  absent  on  the  affected  side ;  the  value  of  palpa- 
tion is  obvious  in  such  cases,  especially  if  laryngoscopy  is 
impossible. 

In  paralysis  of  the  cricothyroid  muscle  the  normal 
vibration  of  the  cricothyroid  membrane  and  the  approxi- 
mation of  the  lower  border  of  the  thyroid  and  upper 
border  of  the  cricoid  cartilages,  normally  felt  in  phona- 
tion,  are  absent. 

If  the  posterior  portion  of  the  upper  border  of  the 
thyroid  is  compressed  and  the  entire  organ  moved  about 
with  the  fingers,  crepitation,  produced  by  the  rubbing  of 
the  posterior  wall  against  the  spinal  column,  is  felt.  This 
crepitation  is  distinguished  from  pathological  crepitation 
by  its  disappearing  if,  during  the  movement,  the  entire 
larynx  is  drawn  forward.  The  phenomenon  occurs  path- 
ologically, so  that  it  can  be  both  felt  and  heard,  in  arthritic 
])rocesses  affecting  the  crico-arytenoidean  articulation. 
(For  details  see  below.) 

It  seems  superfluous  to  say  that  sensitive  spots  must 
always  be  felt  for ;  it  is  important,  however,  to  warn 
against  pronouncing  as  pathological  the  extreme  sensitive- 
ness of  the  superior  laryngeal  nerves,  which  enter  the 
larynx  at  the  center  of  the  upper  lateral  border  of  the 
cricoid  cartilage. 

(5)  AUSCULTATION 

nowadays  is  practically  confined  to  the  sounds  heard  by 
the  unaided  ear  in  respiration  and  in  phonation.     Respi- 


METHODS  OF  EXAMINATION.  27 

ration  is  normally  noiseless,  but  respiratory  sounds  are 
heard  whenever  the  lumen  of  the  upper  air-passages  be- 
comes constricted.  The  term  stridor  is  applied  to  these 
sounds.  Tliey  are  usually  long  drawn  out,  and,  if  there 
is  marked  obstruction,  quite  loud ;  they  are  heard  best  in 
inspiration,  especially  in  laryngeal  stenoses,  but  may  also 
be  audible  in  expiration.  The  reason  of  this  phenomenon 
probably  is  that  air-hunger  in  stenosis  induces  more  in- 
tense inspiration,  while  the  excessive  CO^  production  is 
not  so  distressing,  and  therefore  does  not  excite  expiration 
to  the  same  degree.  (This  difference,  of  course,  disappears 
in  severe  stenoses,  which  tend  to  accelerate  even  the  slower 
expiratory  blast.) 

We  must  not  forget  that  it  is  also  possible  for  the  mov- 
able parts  about  the  aperture  of  the  larynx  to  be  drawn 
down  into  the  constricted  lumen  during  inspiration  (by  a 
sort  of  suction) ;  while,  of  course,  expiration  can  only 
blow  them  out  into  the  open  space  beyond. 

It  happens  not  infrequently  that  the  respiratory  efforts 
lead  to  perverse  innervation  of  the  larynx  and  consequent 
approximation  of  the  true  vocal  cords,  which  only  aggra- 
vates the  stenosis.  Pure  expiratory  stridor  is  probably 
always  due  to  such  false  innervation. 

Although  it  may  be  possible  to  distinguish  between 
laryngeal  and  tracheal  stenosis  by  direct  auscultation  with 
the  stethoscope,  it  is  both  easier  and  surer  to  make  the 
diagnosis  by  direct  inspection. 

In  rare  cases  a  rattling  noise  is  heard  in  respiration,  or 
even  in  phonation,  produced  by  some  obstruction  to  the 
air-current — a  foreign  body  free  to  move  up  and  down,  a 
very  movable  tumor,  or  movable  secretion. 

It  is  important  to  note  the  voice ;  a  practised  ear  can 
make  a  diagnosis  by  the  voice  alone.  Complete  aphonia, 
in  which  the  patient  cannot  speak  above  a  whisper,  occurs 
in  paralysis  of  the  muscles  which  close  the  glottis  and 
stretch  the  cords,  in  nervous  or  in  muscular  affections,  in 
paralysis  of  both  recurrent  nerves,  in  violent  acute  catarrh, 
and  in  destruction  or  rigid  infiltration  of  the  muscles  of 


28  DISEASES  OF  THE  LARYNX. 

the  cords  from  any  cause.  Rough  (raucous),  croaking,  or 
gruntiug  sounds  are  heard  mostly  in  tertiary  syphilis;  a 
hoarse,  discordant  voice,  especially  in  the  second  stage  of 
the  disease.  In  subacute  and  clironic  catarrh  the  dys- 
phonia  often  alternates  with  better,  more  sonorous  tones. 
There  are,  besides,  many  minor  shades  of  difference. 

The  examination  is  by  no  means  complete  even  after 
laryngoscopy  and  all  the  other  diagnostic  methods  of  as- 
certaining the  condition  of  the  larynx  have  been  ex- 
hausted. Only  a  few  unimportant  affections  of  the  larynx 
are  independent  of  systemic  disease  or  of  disease  of 
neighboring  organs. 

Since,  then,  the  interpretation  of  doubtful  cases  will 
always  depend  largely  on  examination  of  the  contiguous 
parts  of  the  air-passages,  especially  the  fauces,  of  the  ali- 
mentary canal,  and  of  the  entire  body,  it  is  always  best, 
in  the  absence  of  a  very  large  experience,  to  make  a  care- 
fid  general  examination  in  order  to  check  even  such  local 
findings  as  seem  to  be  perfectly  clear  and  easy  to  explain  ; 
not  infrequently  a  preconc€'ived  opinion  concerning  the 
primary  cause  of  the  disease  is  in  this  way  shown  to  be 
erroneous.  The  examination  cannot  be  too  thorough  :  in 
no  other  organ  of  the  body  is  disease  so  dependent  on  the 
general  condition  as  in  the  larynx,  and,  conversely,  the 
finding  of  certain  conditions  in  the  larynx  often  throws 
light  on  latent  or  obscure  processes  in  the  entire  organism. 
The  importance  of  these  remarks  will  be  better  appre- 
ciated after  a  careful  study  of  the  histories  accompanying 
the  ])lates. 

PRACTICAL  HINTS   FOR   THE   EXAMINATION. 

A  perfect  technique  in  the  examination  of  the  larynx 
in  the  living  subject  is  only  achieved  by  constant  prac- 
tice, and  it  is  not  to  be  sup])osed  that  any  one  would 
exj)ect  to  learn  it  by  theoretical  instruction  ;  we  therefore 
assume  that  the  reader  has  often  made  the  examination 
on  dead  and  living  sulyects.     As  the  latter  usually  com- 


METHODS  OF  EXAMINATION.  29 

prise  the  individuals  used  in  clinics,  who  have  been  drilled 
for  passive  laryngoscopy,  and  the  few  patients  who,  from 
having  been  through  the  ordeal  so  often,  are  readily  ex- 
amined even  by  beginners,  we  need  hardly  say  that  the 
difficulties  encountered  in  private  practice  are  incompara- 
bly greater ;  in  most  cases  the  physician  is  confronted 
with  organs  which  have  never  been  examined  and  are  ex- 
tremely sensitive.  In  order  to  enable  the  beginner  to 
overcome  these  difficulties  a  few  jwactical  hints  may  not 
be  unAvelcome. 

In  the  first  place,  it  is  always  better  to  make  the  exam- 
ination before  meals ;  there  is  less  danger  of  vomiting 
and,  if  it  does  occur,  it  will  do  less  damage  to  either 
party. 

Have  the  patient  jwotnide  the  tongue  actively,  not  draw 
it  out  with  his  fingers ;  and  then  hold  it  yourself  rather 
than  risk  the  annoyance  of  having  the  patient  release  it 
at  the  most  interesting  moment. 

If  the  tongue  is  so  thick,  or  the  lower  incisors  are  so 
sharp,  that  there  is  danger  of  excessive  friction  of,  or  even 
injury  to,  the  frenum,  the  soft  parts  should  be  protected 
by  placing  a  thick  strip  of  cotton  over  the  teeth.  If 
this  is  put  in  place  with  a  forceps  after  the  tongue  is 
drawn  forward  and  before  it  is  drawn  down,  it  will  not 
slip  off. 

If  the  root  of  the  tongue  bulges  upward,  it  will  often 
have  to  be  pressed  down  with  a  spatula  (a  Tiirck's,  if 
possible)  before  a  view  of  the  uvula  can  be  obtained. 
Compress  gradually,  not  with  a  sudden  violent  movement, 
using,  however,  considerable  force:  firm  pressure  is  easily 
borne,  whereas  timid  little  dabs  only  tickle  the  organ. 
This  precaution,  by  the  way,  should  also  be  observed  in 
laryngoscopy  with  the  spatula  after  Kirstein. 

The  mirror  is  to  be  held  gently  but  firmly  against  the 
uvula ;  not  above  it  or  to  one  side.  If  it  slips  past  the 
mirror,  use  a  larger  one ;  in  general,  the  largest  possible 
mirror  is  always  advisable  because  the  light  is  stronger 
and  the  image  larger. 


30  DISEASES  OF  THE  LARYNX. 

If  the  patient  chokes  before  the  mirror  is  in  place,  or 
even  at  the  first  touch,  make  him  say  '*  a  "  as  in  "  fate '' 
(not  ^^  ah  ^')  very  loud  and  long,  and  introduce  the  mirror 
during  phonation. 

It  is  absolutely  impossible  to  see  the  image  if  the  patient 
holds  his  breath  convulsively  :  the  larynx  is  drawn  high  up 
under  the  root  of  the  tongue,  the  pillars  of  the  fauces 
are  stretched  to  the  utmost,  and  the  glottis  is  closed. 
Many  patients  do  this  as  soon  as  they  open  their  mouths 
and  put  out  their  tongues.  In  such  cases,  before  attempt- 
ing to  introduce  the  mirror,  have  the  patient  take  long, 
deep  breaths  with  the  mouth  in  the  proper  position  to 
receive  the  mirror,  until  the  respiration  is  no  longer  dis- 
turbed by  the  introduction  of  the  instrument.  Psychical 
irritability  is  sometimes  diminished  by  dosing  the  eyes,  but 
they  must  not  be  shut  convulsively,  lest  it  cause  the  oral 
cavity  to  become  narrower. 

Remember  that  the  tendency  to  choke  is  constantly 
aggravated  by  accumulation  of  saliva  from  excessive  re- 
flex secretion ;  the  patient  should  therefore  be  allowed  to 
expectorate,  ivithout  hawking,  as  that  only  aggravates  re- 
flex sensibility.  By  this  means  and  by  suitable  encour- 
agement one  can  also  prevent  constant  swallowing,  which 
is  so  troublesome  and  dims  the  mirror  every  time. 

Never,  not  even  for  practice,  have  the  patient  say  ^^ah," 
but  always  "a,''  as  the  epiglottis  is  only  raised  in  high- 
pitched  notes,  and  often  a  mere  trial-examination  affords 
a  satisfactory  view  of  the  larynx. 

[f,  as  happens  in  rare  instances,  the  epiglottis  even  then 
fails  to  rise  and  exj)ose  the  larynx,  a  slight  pressure  and 
forward  pull  with  a  long  spatula  (FrankePs,  for  instance) 
on  the  median  fold  of  the  glosso-epiglottidean  ligament 
will  bring  about  the  desired  result. 

Choking  and  vomiting  are  sometimes  so  excessive  that 
they  can  only  be  overcome  by  painting  the  parts  to  be 
toucihed  with  cocain.  A  pledget  of  cotton  the  size  of  a 
pea  does  not  hold  enough  of  the  10  per  cent,  solution  to 
make  an  application  to  the  mucous  membrane  at  all  dan- 


METHODS  OF  EXAMINATION.  31 

gerous.^  At  least  three  minutes  should  be  allowed  for  the 
anesthetic  to  take  effect :  if  it  fails  to  act,  it  is  usually 
because  there  has  not  been  time  enough. 

The  choking  depends  more  on  subjective  resistance 
than  on  objective  impossibility  to  overcome  the  irritation  : 
many  patients  will  only  become  quiet  after  a  touch  Avith  a 
probe  has  convinced  them  that  anesthesia  is  complete. 

The  reflector  should  always  be  held  in  front  of  the  eyes, 
not  merely  on  the  forehead,  else  a  part  of  the  light  is  sure 
to  be  intercepted  by  the  upper  lip.  Use  both  eyes,  not 
only  the  one  behind  the  hole.  It  is  not  enough  to  examine 
the  phonatory  image  only ;  the  condition  in  respiration 
should  also  be  studied,  although  it  is  harder  to  see  than 
the  former. 

If  the  case  is  at  all  doubtful,  do  not  neglect  to  ascertain 
the  sensibility  by  testing  with  a  probe.  Remember  that 
the  larynx  forms  only  a  part  of  the  air-tube,  and  that  the 
lungs  and  trachea,  as  well  as  the  upper  passages,  the  nose 
and  throat,  may  furnish  as  important  data  for  the  diagno- 
sis as  the  heart,  the  abdomen,  the  nervous  system,  and  the 
urine.  Above  all,  bear  in  mind  that  disease  of  one  organ 
is  not  always  isolated,  and  that  you  are  first  a  physician 
and  then  a  laryngologist. 

As  regards  treatment,  I  would  add  a  warning  against 
annoying  tlie  patient  more  than  the  whole  trouble  is  worth. 
Often  the  patient  cares  less  about  getting  rid  of  a  slight 
annoyance  than  the  physician,  who  feels  himself  in  duty 
bound  either  by  ambition  or  the  love  of  science.  Let  us 
be  kind  and  noble  as  well  as  helpful ! 

GENERAL  REMARKS  ON  THE  CAUSES  AND  TREAT- 
MENT OF  DISEASES  OF  THE  LARYNX. 

Painting  the  throat  and  gargling  will  not  cure  a  dis- 
eased larynx,  but  suitable  general  treatment,  even  without 

^  [Putting  aside  the  question  of  danger,  we  do  not  think  it  necessary 
to  use  a  sohition  of  such  percentage.  One  of  4  per  cent,  strength  will 
produce  all  the  anesthesia  necessary  to  make  the  examination  success- 
fully.—Ed.] 


32  DISEASES  OF  THE  LARYNX. 

local  applications,  may  accomplish  a  good  deal,  and  it  is 
the  latter  that  is  too  often  neglected.  A  patient  suffering 
from  laryngeal  trouble  should  not  be  allowed  to  talk,  any 
more  than  a  man  with  a  sore  foot  is  allowed  to  walk  :  the 
first  requisite  for  the  cure  of  an  inflamed  or  injured  organ 
is  absolute  rest,  which  incidentally  removes  one  of  the 
commonest  causes,  overexertion.  Loud  talking  should, 
therefore,  be  forbidden  altogetlier ;  the  patient  should 
converse  as  little  as  possible  and  always  in  a  whisper.^ 
The  only  exceptions  are  certain  psychical  or  essential 
paralyses,  when  it  is  desired  to  restore  the  functional 
activity  of  the  organ. 

Smoking  and  drinking,  and  the  eating  of  highly  seasoned 
food,  must  be  restricted  or  prohibited  entirely,  at  least  in 
the  acute  and  subacute  stages. 

The  digestion  must  be  regulated ;  this  is  of  no  small 
importance,  as  constipation  tends  to  aggravate  peripheral 
hyperemias. 

Cough  due  to  disease  of  higher  or  deeper  adjoining 
organs  (nose  and  throat,  lungs  and  bronchi)  must  be 
checked  as  much  as  possible,  for  it  is  one  of  the  worst 
meclianical  irritants  of  the  larynx. 

Still  more  injurious  is  the  hawking  so  often  excited  by 
disturbances  of  secretion  in  the  upper  air-passages  (nose 
and  nasopharynx).  Combined  with  the  dri])ping  of  ])us 
and  mucus  on  the  laryux  from  above,  it  is  one  of  the 
commonest  causes  of  the  various  forms  of  "  chronic  laryn- 
geal catarrh."  The  first  step  in  the  treatment  of  this  dis- 
ease, therefore,  should  be  a  careful  examination  of  the 
upper  organs ;  often  the  entire  treatment  may  consist  ex- 
clusively in  removing  anomalies  in  those  organs. 
•  Local  treatment  is  indicated  ifrst,  in  the  comparatively 
rare  primary  diseases  of  the  larynx  ;  second  1 1/,  whenever 
mechanical  alterations  require  mechanical  interference. 

Liquids,  especially  astringents,  should  be  applied  di- 

^  [If  even  tlie  privilege  of  wliisperinj?  is  permitted,  it  is  too  often 
apt  to  be  abused.  Besides,  whispering  is  but  little,  if  at  all,  less  ob- 
jectionable than  actual  phonation. — Ed.] 


METHODS  OF  EXAM  I  NAT  f  ON.  33 

rectly  by  means  of  a  brush  or  syringe ;  inhalations  are 
generally  useless,  titrate  of  silver  in  2-5  |)er  eent.  solu- 
tion, 2-4  p(!r  eent.  earbolie-ae,i(l  solution,  and  eon(;ontraterl 
laetic  aeid  are  used.^  lehtFiyol  is  an  exeelient  remedy  in 
secondary  catarrh  and  in  scab-formations  :  Jj^.  Ammon. 
sulpho-ichthyol.,  10.0;  glye(;rin.,  40.0;  ].  menth.  pip., 
gtt.  V.  It  is  best  aj>plied  with  a  pledget  of  cotton  at  the 
end  r>f  an  applicator;  the  pledget  is  thrown  away  and 
the  applicator  boiled  after  using.  Spraying  is  not  neces- 
sary, as  a  rule ;  its  use  is  more  a  matter  of  taste. 

The  pledget  of  cotton  is  pressed  lightly  against  the  epi- 
glottis from  behind,  so  that  the  fluid  drips  down  ;  or  it  is 
introdii(;ed  into  the  open  glottis  during  respiration,  when 
its  contents  are  squeezed  out  by  the  approximation  of  the 
cords.  Painting — that  is,  m(!e,}i;ini",;d  rubbing  in — is  in- 
jurious, and  should  be  avoid  •  1  "  pt  in  the  treatment  of 
ulcers  with  (iurbolic  ncid  or-  i,!"i:"  j.cid,  when  it  should  be 
done  energetically  and  thoroughly. 

For  an  astringent  dusting-powder  use  alum  1  :  10, 
with  sach.  lact.  or  amyl  trit.  For  disinfectants  the  iodin 
preparations,  iodoform  and  ioflol,  wvc  ])rine,ipa,lly  used. 

Dusting  with  these  and  other  sitr)ilar  powders  is  confined 
to  open  ulcers ;  in  general,  it  is  to  be  remembered  that 
deep-seated  and  grave  diseases,  esf)ecially  tiibercidosis, 
will  not  yield  to  such  superficial  and  wliolly  inaderpiat^ 
treatment,  f)ut  demand  more  energetic  destructive  meas- 
ures. The  mildest  form  is  cauterization.  Lnnar  canstic 
fusfid  u{)on  the  end  of  a  [)robe,  or  trichlorar;etic  acid,  will 
serve  for  (;auterizing  su|)erficial  ulcers  of  every  kind,  and 
even  for  more  energetic  procedures  against  hypertrophy 
of  the  e[)ithelium,  so  common   in   chronic   inflafnmations. 

Klf'drolyHlH  is  a  more  drastic  nuiasure.  The;  duration 
as  well  as  the  intc^nsity  of  the  dose  can  be  reguhited.  A 
current  of  15-20  ma.  for  five  minutes  is  the  usual  dose. 

'  [For  the  less  experienced  reader  it  may  be  well  to  state  that  the 
use  of  lactic  acid  liad  better  be  begun  with  a  oO  per  cent,  solution  and 
the  strength  gradually  inci-eased.  For  the  earlier  ai)plications  previous 
cocainization  of  the  larynx  will  be  a  wise  precaution. — Fd.] 

3 


34  DISEASES  OF  THE  LARYNX. 

The  requisites  are  an  amperemeter  and  rheostat  to  measure 
the  strencrth  of  the  current  and  to  introduce  and  remove 
it  without  causing  pain.  Ten  to  fifteen  cells  suffice  for  its 
generation.  It  is  applied  with  the  double  needle,  stabbing 
deeply  after  the  parts  have  been  well  cocainized.  It  is 
best  to  screw  the  needle  directly  to  the  conducting  wires. 
The  treatment  is  used  to  remove  secondary  epithelial 
liyperplasiffi  (warts,  '^  pachydermia "),  and  especially  in 
small  tuberculous  infiltrations  ;  sometimes  also  to  melt  out 
the  base  of  a  previously  extirpated  ulcer. 

Gahanocautery  is  still  more  heroic.  The  sharp-pointed 
stabbing  cautery  is  a  powerful  tissue-destroyer.  It  is 
therefore  properly  used  in  nodular  tuberculosis  and  in 
deep  ulcers.  As  the  reaction  is  more  severe  than  in  elec- 
trolysis, great  care  must  be  exercised  in  its  application  ; 
only  the  diseased  parts  must  be  touched,  and  one  must  be 
especially  careful  to  avoid  burning  the  surface.  The  loop 
may  be  successfully  used  to  remove  pedunculated,  hard 
tumors  or  such  as  threaten  hemorrhage. 

Sharp  instruments  are  used  to  separate  or  excise  diseased 
parts. 

Operating-knives,  either  sharp-pointed  or  blunt,  with  a 
cutting-edge,  are  employed  to  make  incisions  in  edematous 
or  purulent  swellings  and  to  remove  flat  ulcers. 

Curets,  single  and  double,  Heryng's  or  Krause's,  are 
used  to  remove  diseased  parts  from  healthy  tissue,  espe- 
cially in  tuberculosis,  and  to  expose  deeper  infiltrations  so 
that  they  may  be  cast  off  more  easily. 

If  curettage  is  resorted  to  at  all,  it  must  be  done  thor- 
oughly, down  to  the  healthy  tissue ;  it  is,  therefore,  indi- 
cated only  when  there  is  reasonable  hope  of  success. 
Furthermore,  the  operation  should  be  exhaustive,  and 
completed  at  one  sitting,  not  split  up  into  innumerable 
little  pickings.  Many  failures  are  attributable  to  such 
senseless  and  ineffectual  methods. 

The  use  of  the  numerous  instruments  devised  for  ex- 
tirpating tumors  (loops,  tonsillotomes,  forceps,  annular 
knives,  etc.)  can  only  be  learnt  by  practice. 


METHODS  OF  EXAMINATION.  35 

In  all  kinds  of  instruments  the  shaft  should  be  bent  to 
the  riglit  near  the  handle,  so  tliat  the  operator's  hand  does 
not  encroach  on  the  field  oF  vision.  The  handles  them- 
selves should  be  flexible.  Frequently  it  is  impossible  to 
reach  the  deeper  and  more  remote  parts  of  the  larynx 
with  certainty,  unless  the  handle  of  the  instrument  has 
been  previously  bent  in  the  proper  direction  according  to 
measurements  obtained  by  means  of  a  sound,  because  the 
oral  cavity  limits  the  play  of  the  instrument. 

Muscular  and  nervous  paralyses  occasionally  require 
electrical  treatment  to  prevent  the  occurrence  of  atrophy  ; 
peripheral  nerve-lesions,  if  amenable  to  treatment  at  all, 
also  appear  to  be  favorably  influenced  by  electricity. 
Whether  the  electricity  is  applied  to  the  larynx  internally 
or  externally  is  a  matter  of  taste.  A  faradic  current, 
strong  enough  to  produce  poAverful,  but  not  painful,  con- 
tractions in  the  tongue,  is  applied  for  from  one-half  to  one 
minute  once  daily  ;  or  a  galvanic  current  of  5  ma.  in- 
ternally and  10-15  ma.  externally,  from  one  to  three 
minutes,  with  change  of  poles  and  interruption.  Great 
care  is  necessary  to  avoid  burning  the  delicate  mucous 
membrane ;  therefore  use  broad  electrodes. 

To  remove  transient  or  chronic  stenoses  we  employ  in- 
tubation after  O'Dwyer,  dilatation  with  bougies  or  tin 
bolts  after  Schrotter  (the  latter  only  after  tracheotomy), 
and  finally  the  insertion  of  chimney-sha])ed  cannulse  after 
Mikulicz  in  thyreotomized  larynges.  But  good  results 
are  often  obtained  without  these  complicated  appliances  in 
less  marked  stenoses  and  membranes,  by  forcing  successive 
tampons  of  increasing  thickness  through  them,  especially 
if  the  treatment  can  be  assisted  by  bloody  dilatation. 


PATHOLOGY  AND  TREATMENT. 


I.  ACUTE  INFLAMMATIONS. 

1.    SUPERFICIAL  INFLAMMATIONS. 
(a)  Idiopathic. 

This  division  includes  all  inflammations  which  directly 
attack  the  larynx  in  consequence  of  unfavorable  external 
influences,  tliough  they  may  be  synchronous  with  disease 
in  other  parts  of  tlie  body. 

First  in  order  is  simple  catarrh,  a  frequent  accompani- 
ment of  coryza. 

;^tiology. — Catching  cold,  especially  if  the  patient 
forces  his  voice  in  defiance  of  noticeable  impairment,  or 
persists  in  the  use  of  tobacco  and  alcoliol.  Inhaling  irri- 
tant gases  or  dust  (street-dust  in  w^indy  weather,  brick- 
dust,  dust  of  clu'omic  acid,  spices,  and  similar  materials 
in  factories  and   warehouses). 

Symptoms. — Dryness  of  the  throat,  slight  difficulty  in 
swallowing  and  in  speaking,  hoarseness  (rough,  deep  v(^ice) 
or  complete  aphonia.  At  first  there  is  slight  cough,  which 
soon  becomes  more  severe ;  it  is  dry  and  irritating,  and 
secretion  is  still  scanty  ;  later,  when  the  secretion  has  be- 
come looser  and  more  copious,  it  is  brought  up  more  easily 
and  with  less  irritation,  at  the  same  time  slight  rales  may 
be  heard.  The  breathing  is  shallow,  as  deep  inspiration 
excites  cough.  The  subjective  symptoms  vary  a  good 
deal  according  to  the  principal   seat  of  the  disease. 

lyaryngeal  Image. — Inflammation  and  slight  swell- 
ing of  the  entire  mucous  membrane  or  of  single  areas.  Later 
a  glairy  secretion  is  seen,  and,  rarely,  toward  the  close,  a 

36 


ACUTE  INFLAMMATIONS.  37 

yellowish  secretion.  Depending  upon  the  seat  of  the  in- 
flammation,  the  epiglottis  and,  perhaps,  the  aryteno-epi- 
glottidean  folds  as  well,  are  seen  to  be  inflamed  (especially 
after  thermal  irritation,  when  dysphagia  is  the  principal 
symptom),  or  the  ventricular  bands  (see  Plate  8,  Fig.  2), 
or  the  true  vocal  cords,  either  in  their  whole  extent  (Plate 
9,  Fig.  1)  or  only  in  part  (Plate  8,  Fig.  1),  in  wdiich  case 
dysphonia  is  the  principal  symptom.  In  very  rare  cases 
the  appearances  are  confined  to  the  interarytenoid  space 
(Pkite  1 9,  Fig.  2),  when  the  voice  may  be  perfectly  clear ; 
while,  on  the  other  hand,  cough  is  incessant  and  uncon- 
trollal)le,  causing  great  discomfort  to  the  patient.  Occa- 
sionally the  mucous  membrane  of  the  under  surface  of  the 
true  vocal  cords  becomes  swollen,  especially  in  children,  a 
condition  which  is  aptly  designated  as  laryngitis  hypo- 
glottica  (pseudocroup). 

In  some  cases  the  hoarseness  is  caused  by  impaired  vi- 
bration of  the  thickened  true  vocal  cords,  in  others  by 
insufficiency  of  the  muscles  concerned  in  phonation,  either 
from  inflammatory  infiltration  or  from  neuritis.  We  there- 
fore meet  with  the  picture  of  paralysis  of  the  internal 
thyro-arytenoid  muscle  (Plate  9,  Fig.  1),  or  of  the  trans- 
verse arytenoid  (Plate  8,  Fig.  1),  or  of  both  together 
(Plate  8,  Fig.  2)  ;  quite  frequently  also  that  of  the  lateral 
crico-arytenoid  muscle  (Fig.  6). 

The  inflammation,  whatever  may  be  its  seat,  sometimes 
goes  on  to  exudation  within  the  mucous  membrane,  re- 
sulting in  slight  edema ;  the  true  vocal  cords  then  appear 
round  like  sausages.  The  integrity  of  the  blood-vessels 
may  be  impaired  by  the  inflammatory  process,  so  as  to 
give  rise  to  small  hemorrhages,  especially  during  a  parox- 
ysm of  coughing  ;  these  hemorrhages  appear  as  blood-red, 
and  later  as  black  spots  in  or  upon  the  mucous  membrane. 
The  delicate  organs  of  singers  are  particularly  liable  to 
suffer  in  this  way  after  functional  abuse.  In  other  cases, 
especially  in  cases  of  long  duration,  the  epithelium  may 
be  softened  by  the  inflammatory  infiltration  and  cast  off. 
If  this  process  is  confined  to  the  surface,  dull  whitish 


38  PATHOLOGY  AND   TREATMENT. 

specks  appear ;  but  if  the  desquamation  reaches  the  mu- 
cosa, shallow  yellowish  depressions,  so-called  erosions  (see 
Plate  11,  Fig.  1),  result,  which  may  become  at  times  quite 
extensive. 

Prognosis. — Spontaneous  cure  if  the  voice  is  allowed 
to  rest ;  if  it  is  overexerted,  and  no  care  is  taken  to  avoid 
fresh  exposure,  chronic  inflammation  develops. 

Treatment. — At  first  only  general,  no  local  treatment: 
sweating,  regulation  of  the  bowels,  Priessnitz  bandage 
al)out  the  throat ;  talking  and  smoking  to  be  forbidden  ; 
lukewarm,  non-irritating  food  and  drink.  Later — after 
ten  to  fourteen  days — perhaps  painting  Avith  a  2-4  per 
cent,  solution  of  nitrate  of  silver ;  in  the  hemorrhagic 
form  or  in  erosions  dusting  with  aluminis  crudi  20.0,  sach. 
lact.  30.0,  dose  1-2  gr.  In  the  last  two  conditions  the 
use  of  the  voice  must  be  strictly  prohibited. 

If  the  erosions  persist  a  long  time,  they  may  be  cauter- 
ized once  with  solid  nitrate  of  silver,  but  on  no  account 
are  they  to  be  painted.  Violent  cough  may  demand 
morphin  (0.1  :  15.0  aq.  dest.,  10-15  drops  three  times  a 
day). 

Acute  catarrh  in  children  presents  some  peculiarities.  The  secretion 
is  scanty  and  there  is  constant,  dry,  barking  cough.  Swellings  in  the 
ventricles,  causing  actual  stenosis,  combined  with  the  extreme  reflex 
sensibility  characteristic  of  childhood,  bring  on  disturbances  of  respira- 
tion in  the  form  of  choking  fits ;  they  are  also  caused  by  perverse  inner- 
vation of  the  adductors  of  the  glottis.  The  similarity  of  these  symptoms 
to  those  of  diphtheria  suggested  the  term  pscudocroup,  but  the  term 
catarrh  is  anatomically  more  correct.  The  attacks  of  stenosis  are  best 
controlled  by  a  cold  douche  in  a  warm  bath.  The  bowels  must  be  care- 
fully regulated,  better  a  little  diarrhea  than  constipation.  Give  2-3 
knife-points  daily  of  pulv.  glycyrrh.  comp, 

(b)  Symptomatic  catarrh  is  met  with  in  all  the  acute  in- 
fectious diseases.  As  it  is  associated  both  in  time  and  in 
situation  with  other  anatomical  altcration.s,  partly  specific 
in  character,  it  will  be  treated  witli  these  separately. 


ACUTE  INFLAMMATIONS.  39 

2.    EXUDATIVE    INFLAMMATIONS. 

(a)  Diphtheria. 

Htiology. — The  Loffler  bacillus  is  now  UDiversally  ac- 
knowleclo:ed  to  be  the  cause  of  this  inflammation.  Its 
action,  however,  undoubtedly  depends  on  individual  dis- 
position and  usually  on  predisposing  external  causes. 
Though  the  latter  may  not  be  absolutely  essential,  they 
furnish  the  only  explanation  for  the  cases  being  most 
numerous  in  winter,  in  regions  characterized  by  sudden 
changes  in  temperature  and  under  unfavorable  hygienic 
conditions.  The  latter  must  not  be  understood  to  mean 
only  poverty ;  poor  children  in  the  country  are  often 
better  off  hygienically  than  rich  children  in  the  city,  and 
the  want  of  cleanliness  among  the  latter  may  be  as  great 
as  in  poorer  families. 

Morbid  Anatomy. — The  first  manifestation  of  the 
morbid  process  is  an  exudation  of  lymphatic  elements  from 
the  blood-vessels.  These  migrating  cells  soon  undergo 
coagulative  necrosis  and  lose  their  structure,  so  that 
nothing  remains  but  a  reticulated  infiltration,  consisting 
chiefly  of  fibrin  from  the  broken-down  cells.  According 
to  the  gravity  of  the  case  and  the  point  of  entrance  of 
the  poison,  this  network  of  fibrin  penetrates  only  the  epi- 
thelium and  superficial,  or  even  deeper,  layers  of  the  mu- 
cosa. At  first  there  is  a  line  of  demarcation  between  the 
necrosed  and  the  living  parts,  and  then  the  former  are 
cast  off.  As  the  infiltration  spreads  out  over  the  surface 
it  comes  away  in  the  form  of  a  membrane.  If  the  de- 
marcation has  been  insufficient,  the  membranes  can  only 
be  removed  with  difficultv  and  bv  sacrificino^  some  of  the 
living  tissue  ;  in  the  contrary  case  they  are  easily  removed. 
That  demarcation  occurs  more  easily  in  superficial  infil- 
trations is  self-evident  and  explains  why  the  latter  sepa- 
rate more  easily ;  hence  there  is  no  fundamental  difference 
between  removable  and  non-removable  membranes. 

If  the  blood-vessels  are  affected  by  the  violence  of  the 
morbid  process  to  such  an  extent  that  the  nutrition  of  the 


40  PATHOLOGY  AND   TREATMENT. 

parts  suffers,  either  from  injury  to  the  walls  and  conse- 
quent impaired  metabolism,  or  from  thrombosis,  ex- 
tensive areas  of  the  mucous  membrane  die  off,  and  Ave 
have  the  so-called  gangrenous  form.  In  the  milder  forms 
the  membranes  often  present  a  sliining  white,  or  occasion- 
ally a  cloudy,  yellowish  appearance ;  the  dreaded  green 
and  black  discolorations,  on  the  other  hand,  are  due  to 
admixture  of  necrotic  blood-corpuscles  by  the  above- 
mentioned  process.  The  appearance  of  tlie  diseased  parts, 
therefore,  varies.  In  the  beginning  the  mucous  membrane 
is  only  slightly  inflamed,  soon  it  becomes  covered  witli 
single,  opaque,  whitish  streaks  or  circular  spots,  or  even 
with  a  broader  ring  of  a  delicate  bluish-white.  Later  tlie 
spots  run  together  to  form  larger  opaque  areas,  white  or 
yellowish-white  in  color.  They  may  appear  in  any  part 
of  the  larynx  ;  sometimes  the  entire  organ  is  covered, 
especially  in  complications  with  disease  of  the  trachea 
and  bronchi.  After  the  adhesions  become  loosened  they 
se})arate  in  tlie  form  of  shreds  or  membranes,  or  even 
regular  tracheal  casts. 

General  Symptoms. — During  the  onset  the  symp- 
toms are  general :  a  feeling  of  discomfort,  lassitude,  loss  of 
appetite,  constipation,  slight  difficulty  in  swallowing,  and 
hoarseness.  If  the  true  nature  of  the  disease  is  not 
already  apparent  from  the  ap])earance  of  the  throat,  it  is 
often  revealed  by  a  dry,  barking  cough  acconq^anying  the 
first  indications  of  laryngeal  disease.  Laryngoscopy,  if 
it  be  j)ossible,  will  even  at  this  stage  show  the  beginning 
of  membrane-formation . 

The  tenq)erature  is  like  that  in  continued  fever,  with 
.^light  morning  remissions;  sometimes  with  greater  fluctu- 
ations, according  to  the  progress  or  abeyance  of  the  morbid 
process.  In  the  most  severe  cases,  the  septic  ones,  the 
temperature  may  be  normal  or  subnormal. 

The  voice  is  affected  in  the  mildest  cases ;  usually  it 
becomes  quite  toneless — after  the  membranes  come  away, 
sometimes  rough  and  dec)),  or  shrill,  in  rapid  alternation. 
The  respiration   is  always  distui-bed  even  to  the  point  of 


ACUTE  INFLAMMATIONS.  41 

extreme  dyspnea,  if  there  is  active  membrane-formation. 
The  dyspnea  shows  itself  in  long  drawn-out,  sighing  in- 
spirations ;  the  head  is  retracted,  and  all  the  accessory 
respiratory  muscles  are  contracted  to  the  utmost ;  the  skin 
is  both  cyanosed  and  pale,  and  cold  to  the  touch  from 
cardiac  weakness. 

The  pulse  is  not  characteristic ;  it  merely  serves  as  a 
manometer  to  register  the  general  reaction  of  the  body. 
Partial  loosening  of  the  membranes  sometimes  betrays 
itself  by  a  rattling  noise  during  inspiration  ;  complete 
separation  is  followed  by  discharge.  The  latter  may 
occur  as  the  final  stage  of  the  process ;  that  is,  during 
convalescence,  or  in  the  course  of  the  disease,  so  that  we 
may  have  new  membranes  forming  after  the  discharge  of 
the  first. 

In  addition  to  the  laryngeal  symptoms,  the  throat,  and 
especially  the  trachea,  bronchi,  and  the  parenchyma  of  the 
lungs,  demand  attention.  It  goes  without  saying  that 
the  general  condition,  as  shown  by  consciousness  or  un- 
consciousness, pulse,  reaction  to  irritants,  state  of  the 
bowels,  must  be  carefully   watched. 

The  duration  is  usually  a  week,  although  sudden  death 
or  more  speedy  recovery  is  not  rare. 

Death  results  either  from  heart-failure  or  from  COg 
poisoning,  or  from  both  together,  since,  in  the  cases  with 
stenosis,  the  heart-failure  is  to  be  attributed  as  much  to 
interference  with  the  circulation  through  insufficient  ven- 
tilation of  the  lungs  and  inadequate  supply  of  oxygen,  as 
to  the  absorption  of  toxins. 

Recovery  may  be  complete  or  may  be  followed  by  se- 
quelae, particularly  in  the  nervous  system  :  paralysis  of 
the  ciliary  muscle  and  loss  of  accommodation  ;  paralysis 
of  the  muscles  of  the  pharynx  and  esophagus,  so  that  par- 
ticles of  food  and  liquids  regurgitate  through  the  nose 
and  cannot  be  swallowed  ;  of  the  sensory  laryngeal  nerves, 
causing  the  patient  to  swallow  into  the  respiratory  tract ; 
and  finally  of  the  motor  laryngeal  nerves  which  may  re- 
sult in  prolonged  paralysis  of  the  true  vocal  cords  (see 


42  PATHOLOGY  AND  TREATMENT. 

Plate  13,  Fig.  2).  The  life  of  the  patient  may  even  be 
threatened  by  paralysis  of  the  plirenic  or  of  the  pneumo- 
gastric  nerve,  resulting  in  respiratory  insufficiency  and 
impaired  heart-action ;  even  pareses  and  paralyses  of  the 
extremities  are  among  the  possible  sequelae. 

Fortunately,  however,  these  nervous  disturbances  are 
rare  compared  with  sequeke  in  the  lymphatic  system  and  in 
the  ear.  The  latter  frequently  follow  complications  of 
the  nose  and  throat,  and  are  sufficiently  important  to  merit 
a  passing  mention  ;  they  are — permanent  enlargements  of 
the  palatine  and  pharyngeal  tonsils  and  purulent  disease 
of  the  middle  ear. 

The  treatment  must  be  more  general  than  local.  The 
remedy  of  prime  importance  is  antitoxin.  Although  it 
may  be  years  before  we  can  judge  of  its  true  value,  its 
evident  harmlessness  and  very  successful  clinical  career 
justify  and  even  compel  its  use.  Other  therapeutic 
measures  must,  however,  not  be  neglected,  especially  such 
as  are  indicated  by  local  alterations. 

We  cannot  here  go  into  the  treatment  required  in  com- 
plications or  in  primary  formations  of  foci  in  the  throat. 

Very  little  can  be  done  in  the  larynx  itself.  In  a  few 
cases  the  membranes  may  be  loosened  and  wiped  away 
with  tampons  dipped  in  lime-water,  but  this  is  not  often 
successful,  and  half-way  measures  only  produce  dangerous 
irritation.  CcmMics  are  absolutely  oontra-indicated.  The 
loosening  process  may  be  assisted  by  constant  inhalations 
of  moist  air,  vapor  of  lime-water  being  the  best ;  the 
value  of  all  other  remedies,  even  of  the  vaunted  emetics, 
is  very  questionable.  Deep  breathing  and  vigorous  ex- 
pectoration may  be  successfully  induced  by  cold  douches. 
If  the  temperature  is  high,  the  douches  may  be  given  in 
an  empty  tub  ;  if  moderate,  in  a  tepid  bath  (50°  C.)  with 
watorat  12°-15°  C. 

The  bowels  are  to  be  regulated.  Nutrition  must  be 
encouraged  by  giving  small  doses  of  stimulating  foods 
and  condiments  at  fre(iuent  intervals  :  beef-tea,  chaudcau, 
egg-nogg,  warm  beer  Avith  the  yolk  of  an  egg,  biscuits. 


ACUTE  INFLAMMATIONS.  43 

boiled  chopped  meatj  plenty  of  milk,  and  occasionally, 
but  only  when  the  strength  begins  to  fail,  alcohol  in  the 
form  of  somewhat  diluted  Cognac  or  good  Bordeaux. 

If  disturbances  of  the  respiration  manifest  themselves 
in  the  form  of  frequent  choking  tits  or  even  lasting  dysp- 
nea, it  is  better  to  interfere  too  soon  than  too  late.  If 
the  bronchi  are  still  open,  simple  intubation  may  be  sufft- 
cient ;  but  if  they,  as  well  as  the  trachea,  are  already  in- 
volved and  the  tubes  are  in  imminent  danger  of  becoming 
clogged,  or  if  the  external  conditions  (lack  of  necessary 
attendants)  preclude  such  measures,  tracheotomy  is  to  be 
preferred.  The  operation  should  not  be  delayed  till  the 
stage  of  asphyxia  has  set  in  (cold,  cyanosis,  deep  traction 
of  the  diaphragm  on  the  thorax),  but  even  then  it  should 
not  be  omitted. 

The  author  prefers  high  tracheotomy,  because  it  avoids 
the  thyroid  gland,  which  can  be  safely  separated  from  the 
upper  margin  of  the  cricoid  cartilage  by  means  of  Rose's 
transverse  incision.  Care  must  be  taken  not  to  injure  or 
divide  the  cricoid  cartilage,  as  cricotomy  is  frequently  fol- 
lowed by  the  dreaded  granulation  which  interferes  so 
much  with  removal  of  the  tubes. 

During  convalescence  disturbances  of  accommodation 
must  be  looked  out  for  as  precursors  of  other  paralyses. 
If  paralysis  of  the  esophageal  muscles  or  of  the  sensory 
nerves  of  the  larynx  supervenes  (cough  in  swallowing), 
the  patient  should  immediately  be  fed  through  a  sound  or 
per  rectum  exclusively ;  the  former  method  is  to  be  pre- 
ferred. Paralysis  of  the  vagus  is  combated  with  complete 
rest  and  digitalis.  Strychnin-injections  are  futile,  the 
paralysis  progressing  serenely  in  spite  of  them. 

Symptomatic  diphtheria  may  be  due  to  other  delete- 
rious causes,  whenever  a  necrotic  process  in  the  epithe- 
lium is  accompanied  by  inflammatory  phenomena  in  the 
mucosa ;  membrane-formation  is  therefore  not  a  specific 
anatomical  evidence  of  such  processes.  It  occurs  after 
scaldings  of  the  larynx  through  inhalations  of  steam  or 
irritant  gases  (ammonia)  and  in  the  course  of  scarlet  fever 


44  PATHOLOGY  AND   TREATMEST. 

and  small-pox.  These  affections  are  therefore  identical 
with  diphtheria  only  in  an  anatomical  sense,  and  etiologi- 
cally  qnite  distinct. 

It  follows  that  the  treatment  is  purely  symptomatic, 
directed  against  a  possible  stenosis  :  intubation  or  traclic- 
otomy. 

3.   INFLAMMATIONS  OF   THE   INTERSTITIAL   TISSUE. 

These  may  be  divided,  according  to  the  kind  and  degree 
of  the  inflammatory  infiltration,  into  simple  edema,  in 
which  a  serous  exudation  into  the  submucnsa  is  associated 
with  very  slight  round-celled  infiltration,  and  jjJiIerjmoni<, 
in  which  cellular  infiltration  is  the  prominent  feature. 
Although  the  two  forms  may  l)e  present  at  the  same  time 
and  in  the  same  situation,  and  be  due  to  the  same  causes, 
we  are  nevertheless  justified  in  making  the  anatomical 
distinction,  since  the  treatment  will  be  influenced  by  the 
form  of  the  inflammation  in  s])ecial  cases.  Xor  is  it  su- 
perfluous to  describe  separately  simple  laryngeal  erysipelas 
with  its  typical  general  and  local  phenomena,  in  order  to 
preserve  the  analogy  with  dermatological  nomenclature. 
If  we  remember  that  all  these  varieties  are  essentially 
identical  when  dependent  on  an  ii\fectwus  process,  it  will 
help  us  to  form  a  clear  and  logical  idea  of  them.  Their 
true  nature  will  be  better  understood  if  we  divide  them 
into  infectious  and  non-infectious  forms. 

(a)  Infectious  Interstitial  Inflammations. 
(«)  Primary  Forms. 

etiology. — Invasion  by  specific  micro-organisms  :  the 
streptococcus  pyogenes,  the  various  forms  of  staphylococci, 
the  pneumococcus,  and  possibly  the  bacterium  coli. 

The  way  is  ()])ened  by  inflammations  in  neighboring 
organs,  especially  the  throat,  the  nasal  cavities,  and  the 
tongue.  Entrance  is  eff*ected  either  through  the  lymph- 
spaces,  or   through    traumatic   lesions   which   may   be   so 


ACUTE  INFLAMMATIONS.  45 

small  as  to  be  invisible — such  as  are  produced  by  a  foreign 
body^  for  instance. 

Metastases  through  the  lymphatic  glands  and  vessels 
are  possible,  though  very  rare. 

It  is  quite  unnecessary  to  construct  a  specific  disease 
(^^  infectious  angina  ^^)  out  of  any  of  these  inflammations. 
They  are  entirely  analogous  to  panaris  (felons),  erysipelas, 
and  phlegmon  on  the  surface  of  the  body. 

lyOcal  Phenomena. — In  edema  the  swelling  is  sharply 
defined,  as  a  rule,  yellowish-gray  or  yellow  in  color,  occa- 
sionally reddish  and  glistening ;  in  the  erysipelatous  form 
the  swelling  is  similar,  but  very  red ;  in  the  phlegmonous 
variety  the  infiltration  is  tougher  and  the  outline  is  more 
irregular.  Collateral  edema  may  occur  from  pressure  on 
the  veins  by  the  infiltration.  In  rapidly  fatal  cases  it 
may  be  impossible  to  recognize  any  stages  in  the  local 
inflammation. 

In  the  final  stage  there  is  either  gradual  reduction  of 
the  swelling,  or  abscess-formation,  preceded  by  a  yellowish 
gathering  at  one  point. 

The  infiltrations  are  2:reatest  in  the  looser  tissues,  the 
epiglottis  or  the  investment  of  the  arytenoid  cartilages. 
They  usually  end  where  these  tissues  have  their  attach- 
ment to  denser  ones ;  if  the  latter  also  become  softened, 
an  atypical,  but  not  abnormal,  extension  of  the  process 
occurs. 

In  the  laryngeal  image  the  parts  involved  are  seen  to 
be  altered  by  convolutions  of  various  shapes  and  hues, 
according  to  the  locality  and  the  variety  of  infiltration 
present :  the  epiglottis  swells  on  one  side  (Plate  8,  Fig.  1), 
or  on  both  (Plate  7,  Fig.  2) — then  usually  in  the  form  of 
a  turban  ;  the  true  vocal  cords  are  thickened  and  resemble 
sausages ;  the  posterior  wall  is  converted  into  a  thick 
bolster  (Plate  25,  Fig.  1).  The  lumen  of  the  larynx  is 
constricted  in  various  planes,  depending  on  the  site  and 
severity  of  the  process ;  sometimes  it  becomes  completely 
obstructed,  especially  in  swellings  of  the  ventricles. 

General  Symptoms. — Fever,  ranging  from  38.5°  to 


46  PATHOLOGY  AND   TREATMENT. 

the  highest  temperatures,  in  mild,  simple  forms  lasting 
several  days,  with  slight  morning  remissions,  in  others 
presenting  the  jerky  type  of  erysipelas.  In  cases  of 
longer  duration,  ending  in  pus-formation,  the  temperature 
presents  the  irregular  character  of  septic  fever ;  occasion- 
ally, in  the  severe  septic  forms,  the  temperature  may  be 
very  low  or  even  subnormal.  The  pulse  corresponds  to 
the  fever  :  strong  and  full,  or  very  frequent,  small,  and 
compressible.  The  patient  feels  very  sick ;  in  severe 
cases  we  may  have  the  typhoid  state.  Frequently  there 
are  headache  and  constipation. 

Great  pain  in  the  throat  on  swallowing  and  speaking,  a 
feelincr  of  tension  and  drvness,  constant  desire  to  swallow 
and,  consequently,  increased  secretion  of  saliva  and  mucus. 

The  inflammatory  swelling  may  spread  to  the  glands 
and  to  the  connective  tissue  of  the  neck  ;  the  swelling  in 
the  latter  is  sometimes  edematous,  sometimes  of  a  board- 
like hardness.  A  corresponding  affection  of  the  fauces 
and  tongue  is  usually  to  be  interpreted  as  a  primary 
trouble. 

Dyspnea  sets  in  as  soon  as  the  inflammation  attacks  the 
aperture  of  the  larynx  or  deeper  parts;  it  is  rarely  caused 
by  the  epiglottis  alone.  In  the  former  case  there  are 
hoarseness  and  aphonia. 

The  course  is  characterized  by  sudden  onset  and  rapid 
increase  in  the  symptoms.  Dyspnea  and  suffocation  in 
many  cases  set  in  early;  in  grave,  septic  cases  death  some- 
times occurs  from  the  toxemia  alone,  before  the  occurrence 
of  stenosis.  In  favorable  cases  recovery  occurs  in  from  a 
few  days  to  two  weeks,  with,  at  times,  abscess-formation 
as  the  final  stage. 

The  diagnosis  is  based  on  the  sudden  onset  without 
previous  disease,  or  immediately  after  a  corresponding 
inflammation  in  higher  situations,  as  acute  syphilitic  dis- 
ease may  present  the  same  clinical  picture.  The  differen- 
tial diagnosis  from  typhoid  and  meningitis  is  made  by  the 
aid  of  laryngoscopy. 

Treatment. — Apply  moist  bandages  to  the  throat  and 


ACUTE  INFLAMMATIONS.  47 

have  the  patient  swallow  cracked  ice ;  talking  is  to  be  for- 
bidden and  the  bowels  must  be  kept  open.  Possible  car- 
diac weakness  must  be  properly  treated.  If  stenosis 
occurs,  resort  to  deep  puncturing  of  the  swollen  parts 
and,  if  possible,  inject  a  few  drops  of  a  2  per  cent,  solu- 
tion of  carbolic  acid  ;  early  tracheotomy  as  a  prophylactic 
measure  rather  than  too  late. 

Always  search  for  the  purulent  focus  and  open  it  as 
early  as  possible  (phlegmons  in  the  fauces  and  throat, 
caries  or  periostitis  of  the  teeth,  abscess  on  the  tongue, 
etc.). 

In  all  cases  where  the  swelling  extends  beyond  the  epi- 
glottis the  patient  should  be  kept  under  constant  and 
careful  supervision,  as  life-threatening  symptoms  often 
appear  quite  unexpectedly. 

(/9)  Any  of  the  foregoing  conditions  may  occur  as  sec- 
ondary processes  in  the  acute  infectious  diseases.  They 
must  then  be  interpreted  as  mixed  infections ;  that  is,  as 
the  products  of  the  above-mentioned  inflammatory  and 
pyogenic  bacteria,  wdiose  entrance  was  made  possible  by 
the  specific  lesion  in  the  mucous  membrane. 

Metastatic  abscesses  occasionally  occur.  The  symptoms 
are  sometimes  very  pronounced  (Plate  6,  Fig.  1 ;  Plate 
26,  Fig.  1).  Course,  diagnosis,  and  treatment  are  the 
same  as  in  the  idiopathic  form. 

(b)  Non=infectious  Interstitial  Inflammations. 

The  number  of  these  is  extremely  small,  being  limited 
to  chemical  and  thermal  lesions.  Accidental  corrosions 
(from  swallowing  caustic  lyes  or  acids)  or  the  therapeutic 
application  of  concentrated  solutions  of  nitrate  of  silver 
or  of  chromic  acid  may  produce  edema  in  the  affected 
parts ;  it  may  also  occur  after  scalding  of  the  larynx  by 
the  sW'allowing  of  hot  liquids  or  the  inhaling  of  hot  va- 
pors, or  after  therapeutic  heat-applications.  These  lesions 
present  in  addition  other  anatomical  features,  and  will 
therefore  be  treated  elsewdiere. 


48  PATHOLOGY  AND   TREATMENT. 

The  tissue-destruction  brought  about  by  such  accidents 
may  in  turn  give  rise  to  infectious  inflammations,  so  that 
a  division  on  etiological  grounds  is  impossible  in  the  later 
stages. 

4.    INFLAMMATIONS   OF   THE   MUSCLES. 

These  hardly  ever  occur  as  primary  affections,  but  they 
accompany  catarrhal  or  interstitial  processes  and  manifest 
themselves  in  pareses  or  even  paralyses  of  certain  muscle- 
groups.  One  of  the  commonest  phenomena  in  acute  or 
subacute  catarrh  is  paresis  of  the  thyro-arytenoid  muscles 
(Plate  9,  Fig.  1),  next  of  the  transverse  arytenoid  muscle 
(Plate  8,  Fig.  1)  ;  not  infrequently  the  adductor  muscles 
are  involved  ;  in  fact,  any  simple  or  mixed  form  of  paresis 
may  be  met  with  (Plate  8,  Fig.  2).  The  sudden  appear- 
ance of  dyspnea  in  the  course  of  an  apparently  mild  or 
interstitial  inflammation  is  sometimes  explained  by  an  in- 
flammatory palsy  of  the  abductor  muscles.  The  picture 
of  median,  or  at  least  cadaveric,  position  is  not  rare  in 
affections  of  the  posterior  wall  (Plate  22,  Fig.  2,  and 
Plate  25,  Fig.  1),  and  simple  swellings  may  produce  the 
same  effect  by  accidental  inflammation  or  collateral  edema. 

Finally,  disturl>ances  of  deglutition  (mis-swallowing  or 
mere  reflex  cough)  are  sometimes  attributable  to  inflam- 
matory palsy  of  the  sphincter  muscles  of  the  larynx  (all 
except  the  cricothyroid  and  posterior  crico-arytenoid  mus- 
cles) and  of  the  depressor  of  the  epiglottis  (thyro-epiglot- 
tideus  muscle). 

Apparent  primary  '^  rheumatic '*  paresis  of  one  or  more 
muscles  ])rol>ably  dejiends  less  on  inflammation  than  on 
intramuscular  hemorrhages,  such  as  sometimes  follow 
sudden  exertion.  Sudden  paralysis  occurring  in  the  course 
of  a  catarrh  may  be  explained  in  this  way. 

The  iinaf/e  is  always  tliat  of  p(^ripheral  palsy. 

The  disease  usually  disa})pears  with  the  jirimary  cause 
and  requires  no  treatment,  at  least  in  the  acute  stage. 


ACUTE  INFLAMMATIONS.  49 

5.   INFLAMMATIONS   OF   THE   JOINTS. 

(a)  These  may  occur  as  primary  affections,  presenting  a 
clinical  j^icture  which  is  calculated  to  mask  the  real  con- 
dition of  affairs.  This  is  true  particularly  of  the  very 
common  localization  in  the  crico-arytenoid  articulation. 
(The  author  has  never  seen  a  primary  lesion  in  other 
joints,  which,  of  course,  does  not  preclude  their  occurrence.) 
Of  the  morbid  anatomy  nothing  is  known.  As  in  other 
joints,  there  is  at  first  probably  a  serous  synovitis  which 
may,  of  course,  run  on  to  a  plastic  and  purulent  form. 

The  etiology  embraces  colds  and  acute  infections. 
The  latter  will  be  assumed  in  cases  which  are  feverish 
from  the  start,  especially  if  they  are  preceded  or  accom- 
panied by  a  lacunar  angina.  Occasionally  the  cause  may 
be  found  in  a  traumatism. 

Symptoms. — The  patient  complains  of  an  odd,  un- 
comfortable feeling  on  either  side  of  the  throat,  especially 
during  the  act  of  swallowing;  it  may  also  be  referred  to 
the  angle  of  the  jaw  or  the  hyoid  bone,  or  the  glands.  It 
is  most  pronounced  when  the  patient  assumes  the  recum- 
bent podure  (passive  dorsal),  especially  if  he  swallows  at 
the  same  time.  Palpation  reveals  pain  on  pressure  of  the 
affected  side,  in  the  "region  of  the  crico-arytenoid  articu- 
lation,'' the  posterior  extremity  of  the  upper  margin  of 
the  cricoid.  At  the  same  time  that  pressure  is  exerted  at 
this  spot  the  laryngoscope  ought  to  show  an  inward 
movement  of  the  corresponding  arytenoid  cartilage  to 
make  the  diagnosis  certain.  Pain  is  also  felt  if  the  region 
of  the  joint  is  touched  with  a  probe  from  the  esophageal 
side. 

If  the  entire  cricoid  cartilage  is  carefully  fixed  with 
one  hand  and  the  right  spot  is  pressed  with  the  other, 
crepitation  may  sometimes  be  both  felt  and  heard,  caused 
by  friction  of  the  inflamed,  rough  articular  surfaces. 

Quite  frequently  laryngoscopy  shows  no  alterations.  It 
is  only  after  neighboring  parts  have  been  invaded  by  the 
inflammation  that  periarthritis  manifests  itself  in  swelling 


50  PATHOLOGY  AND   TREATMENT. 

and  redness  of  the  soft  parts  covering  the  articulation — 
perhaps  even  of  the  posterior  portions  of  the  true  and 
false  vocal  cords.  The  mobility  of  the  true  vocal  cords 
is  usually  not  affected  except  in  very  severe  inflamma- 
tions, in  whicli  case  the  motion  is  uneven  and  jVr/,-^  instead 
of  smooth  and  gliding ;  or  the  parts  may  even  become 
fixed  in  any  position.  It  will  be  impossible  to  distinguish 
such  cases  from  paralysis,  except  in  the  rare  instances 
where  the  abnormal  position  differs  from  that  found  typi- 
cally in  paralysis  ;  to  distinguish  them  from  perichondritis 
during  life  is  practically  impossible.  It  follows  that  only 
the  milder  stages  are  susceptible  of  diagnosis.  For  simi- 
lar reasons  purulent  synovitis  cannot  be  diagnosed  in  vivo, 
as  the  symptoms  must  coincide  with  those  of  phlegmon 
and  attritions. 

Treatment, — Priessnitz  bandage  ;  rubbing  the  painful 
spot  with  ung,  bellad.  15.0,  ung.  ciner.  5.0,  the  size  of  a 
pea ;  laxatives. 

(6)  Secondary  acute  articular  inflammation  is  unques- 
tionably much  more  frequent  than  is  generally  known  ;  it 
occurs  principally  as  a  localization  of  acute  articular 
rheumatism.  Syphilitic  and  tuberculous  processes  also 
attack  this  region.  The  former  can  only  be  recognized 
by  obtaining  a  clear  history  of  infection  or  inheritance ; 
the  latter,  no  doubt  on  account  of  the  virulence  of  the 
specific  cause,  does  not  appear  to  have  been  met  with  ex- 
cept in  complication  with  other  conditions  :  swelling  and 
ultimate  destruction  of  the  adjoining  parts.  In  all  cases 
Avhere  there  is  atypical  disturbance  of  movement^  out  of  all 
pro})ortion  to  visible  alterations,  the  cause  must  be  sought 
in  the  joint,  as  well  as  in  a  possible  dyscrasia,  so  that  (in 
syphilis)  something  may  yet  be  accomplished  by  timely 
treatment.  In  all  such  cases  and  in  cases  due  to  typJioid 
and  influenza  we  have  to  deal  more  with  extensive  chon- 
dritis and  perichondritis  and  their  phenomena  than  with 
simple  joint-lesions ;  still  it  may  hel])  to  clear  up  many 
doubtful  cases  if  the  joint  itself  is  carefully  considered  in 
the  diagnosis. 


ACUTE  INFLAMMATIONS.  51 

Prognosis. — Hecoveiy  is  the  usual  termination  ;  occa- 
sionally, however,  more  or  less  permanent  disturbances  of 
movement,  witliout  further  inflammation,  remain  in  the 
form  of  partial  or  complete  ankyloses.  The  former  are 
characterized  by  imperfect  excursion  of  one  or  both  true 
vocal  cords  in  both  directions,  or  by  a  variation  in  mobility 
— that  is  to  say,  fixation  is  seen  in  different  positions  at 
different  examinations — or  the  ankylosis  may  betray  itself 
by  the  uneven,  jerky  movements,  as  in  acute  inflammation. 
Complete  ankylosis  can  be  distinguished  from  joaralysis 
only  when  the  true  vocal  cord  is  fixed  in  a  position  which 
is  atypical  of  muscular  or  nervous  palsy  ;  ankylosis  may 
be  inferred,  even  when  the  position  is  typical  of  paralysis, 
if  after  prolonged  observation  no  local  or  general  cause 
can  be  found  for  peripheral  or  central  paralysis.  Peri- 
arthritic  inflammations,  or  the  remains  of  such,  are  char- 
acterized by  permanent  thickening,  in  addition  to  the 
abnormal  fixation.  Treatment  of  these  ankyloses  is  usu- 
ally of  no  avail.  If,  however,  the  true  vocal  cords  are 
fixed  in  adduction,  an  attempt  becomes  imperative  on 
account  of  the  grave  dyspnea.  External  massage  and 
gradual  widening  from  within  are  indicated. 

The  treatment  of  active  processes  is  therefore  the 
same  as  that  described  under  the  respective  heads  of  those 
diseases. 

6.    INFLAMMATIONS    OF    THE    PERICHONDRIUM. 

Primary  perichondritis  is  very  rare,  and  is  probably 
the  expression  of  an  infectious  process  which  escapes  de- 
tection. "Rheumatic"  forms  exist  only  in  the  imagina- 
tion of  the  perplexed  diagnostician. 

With  more  probability  the  cause  has  been  sought  in 
traumatisms  which  exposed  the  perichondrium  to  direct 
infection  or  favored  its  gradual  advance. 

Secondary  perichondritis  is  more  common,  either  as  the 
direct  result  of  a  specific  infection  or  in  consequence  of  a 
mixed  infection  after  a  specific  destructive  process.  Pyemic 


52  PATHOLOGY  AND   TREATMENT. 

metastases,  small-pox,  and  typhoid  fever  follow  the  first 
method  ;  diphtheria,  tuberculosis,  and  malignant  tumors 
prefer  the  second  ;  syphilis  acts  in  both  ways. 

The  morbid  anatomy  presents  the  usual  variations ;  be- 
ginning with  simple  swelling  and  running  on  to  serous, 
later  to  fibroplastic  and  purulent,  cellular  exudation,  and 
finally  to  necrosis.  The  exudate  usually  collects  between 
the  cartilage  and  its  investing  membrane  (perichondrium), 
so  that  the  swelling  is  at  first  subperichondral.  From 
there  the  exudate  frequently  breaks  through  to  the  outer 
surface,  and  gives  rise  to  secondary  swelling  and  infiltra- 
tion in  the  interstitial  tissue  (secondary  edema  and  phleg- 
mon and  superficial  abscess-formation).  The  forcible 
separation  of  the  perichondrium  from  the  cartilage  is  fol- 
lowed by  the  changes  which  necessarily  ensue  when  a 
tissue  is  separated  from  its  matrix — retrogressive  nutritive 
disturbances  in  the  form  of  partial  atrophy  or  total  necro- 
sis. If  the  process  is  arrested  in  the  first  stage  and  the 
nutrition  of  the  cartilage  is  restored,  the  changes  will  be 
confined  to  the  thickenings  caused  by  the  infiltration,  or, 
possibly,  to  adhesions  in  the  region  of  the  joints,  which 
may  then  give  rise  to  motile  disturbances.  Sometimes, 
especially  in  tuberculosis,  ossification  of  the  cartilage 
forms  the  final  stage  of  the  nutritive  disturbance. 

In  the  more  advanced  stages  and  in  more  intense  in- 
flammations the  cartilage  becomes  necrosed  as  a  result  of 
the  impaired  nutrition.  If  the  necrosis  is  only  partial, 
the  necrosed  parts  may  be  absorbed  and  leave  only  a  de- 
formity ;  but  if  the  necrosis  is  at  all  extensive  and  the  in- 
flammatory process  continues  after  necrosis  has  set  in, 
sequestra  result  and  persist  for  a  long  time,  setting  up  a 
constantly  recurring  irritation  in  the  soft  parts,  or  they 
may  be  cast  off  in  a  short  time.  Which  of  these  pro- 
cesses will  occur  in  a  particular  case  depends,  of  course,  on 
the  primary  cause ;  little  can  be  hoped  for  in  tuberculosis 
or  in  syphilis,  or  in  any  condition  where  there  is  a  malign 
influence  constantly  at  work. 

The  clinical  picture  presents  some  special  features,  in 


ACUTE  INFLAMMATIONS.  53 

addition  to  those  already  mentioned^  according  to  the 
localization  of  the  process.  Perichondritis  of  the  thyroid 
cartilage  manifests  itself  on  the  outside  by  swelling  of  the 
alse,  which  can  readily  be  felt;  the  painful  region  is  sharply 
defined.  There  may  also  be  an  in^vard  bulging,  which  is 
then  seen  belo\\^  the  true  vocal  cords  in  the  anterior  angle. 
However,  this  is  the  least  frequent  localization. 

The  perichondrium  of  the  arytenoid  cartilages  is  more  fre- 
quently attacked,  perhaps  because  they  play  such  an  active 
part  in  the  function  of  the  organ.  The  consequences  are 
swelling  over  the  cuneiform  cartilages,  abnormal  move- 
ments— that  is,  delayed  action  of  the  true  vocal  cords. 
Whether  this  is  due  to  disuse  of  the  joint  or  to  destruction 
of  the  muscle-attachments  cannot  be  determined  during 
life,  and  is  quite  immaterial  from  a  clinical  point  of  view. 
The  disease  can  be  reco2:nized  with  certaintv  onlv  when 
the  symptoms  are  very  pronounced,  especially  if  the  re- 
sulting necrosis  can  be  reached  with  the  probe  or  leads  to 
the  separation  of  a  sequestrum.  The  swelling  may  ex- 
tend beyond  the  vocal  process — that  is,  over  the  true  vocal 
cord,  and  thus  facilitate  differentiation  from  other  affections. 

Secondary  perichondritis  in  the  cricoid  cartilage  is  very 
common.  Typhoid,  syphilis,  and  tuberculosis  preferably 
attack  this  cartilage.  The  posterior  surface,  from  its  ex- 
posure to  the  eifects  of  friction  and  decubitus,  is  a  favorite 
site,  although  the  inflammation  in  this  cartilage  commonly 
proceeds  from  the  upper  articular  surface  toward  the  ary- 
tenoid cartilages.  The  latter  are  almost  always  found  to 
be  involved  in  an  advanced  necrosis.  Hence  the  swelling 
is  often  found  in  the  same  spot,  as  in  perichondritis  of  the 
arytenoid  cartilages ;  it  is  typical  only  when  seen  beneath 
the  true  vocal  cords  in  the  form  of  sub-cordal  convolu- 
tions (Plate  28,  Fig.  2).  Perichondritis  in  this  situation 
often  produces  grave  stenoses,  as  the  posterior  crico-aryte- 
noid  muscles  and  the  crico-arytenoid  articulation  become 
involved. 

Perichondritis  of  the  smaller  cartilages  cannot  be  re- 
cognized clinically. 


54        PATHOLOGY  AND  TREATMENT. 

The  treatment  depends  upon  the  primary  cause. 
Traumatic  infectious  perichondritis  calls  for  opening  of 
the  foci  and  removal  of  the  secretions,  also  incision,  usu- 
ally from  without,  tamponage,  and  drainage.  A  syph- 
ilitic process  may  sometimes  be  arrested  by  general  treat- 
ment. Tuberculous  forms  are  usually  associated  with  a 
grave  general  condition,  so  that  any  attempt  at  treatment 
is  hopeless ;  still,  even  tuberculous  necroses  should  be 
treated  according  to  general  surgical  principles  whenever 
they  appear  principally  as  local  manifestations. 

Perichondritic  stenosis  is  the  commonest  indication  for 
tracheotomy  in  cases  of  chronic  dyspnea. 

7.   SYMPTOMATIC   (COMPLICATION)   FORMS   OF   ACUTE 
INFLAMMATIONS. 

The  inflammations  which  accompany  the  acute  exan- 
themata, although  they  have  not  often  been  described, 
occur  very  frequently. 

Measles  rarely  runs  its  course  without  laryngitis.  It 
appears  usually  in  the  mildest  form  of  diifuse  catarrh, 
characterized  by  hoarseness  and  aphonia,  and  appearing 
in  the  mirror  as  a  diffuse  redness  and  slight  swelling. 
The  interstitial  tissue  may  be  invaded  by  the  inflammation, 
and  the  slight  edematous  swelling  which  results  may  pro- 
duce in  young  children  subjective  or  objective  stenoses. 
This  incipient  form  of  the  inflammation  often  resembles 
a  specific  exanthema ;  the  redness  appears  in  spots,  as  on 
the  skin,  and  the  infiltration  being  stronger  at  certain 
points  (inside  the  follicles)  gives  rise  to  minute  papules 
analogous  to  the  small  eminences  felt  in  the  skin  and  due 
to  infiltration  of  the  hair-follicles. 

Later  the  ei)ithelium  may  become  macerated  and  cast 
off,  so  that  the  mucous  membrane  assumes  a  dull,  velvety 
sheen.  In  the  parts  which  are  functionally  active  and 
subject  to  friction  erosions  may  appear,  extending  as  far 
as,  or  even  within,  the  mucosa  (the  true  vocal  cords,  vocal 
processes,  and  especially  the  arytenoid  region).    Fibrinous 


ACUTE  INFLAMMATIONS.  55 

exudation  into  the  epithelium  and  mucosa  is  another 
common  symptom  of  the  local  inflammation. 

The  symptoms  are  barkings  and  sometimes  noiseless 
coughj  and  eventually  dyspnea. 

The  treatment  is  principally  directed  against  the  dysp- 
nea :  massage  of  the  throat  with  mercurial  ointment ; 
warm,  moist  bandages  ;  laxatives  ;  timely  tracheotomy,  if 
indicated.  Generally  the  parts  heal  spontaneously.  To 
avoid  ulceration,  or  to  procure  rest  if  it  is  present,  the 
cough  should  be  controlled  with  small  doses  of  morphin, 
unless  contraindicated  by  the  condition  of  the  lungs  and 
bronchi.  Running  ulcers  are  almost  invariably  tubercu- 
lous, and  do  not  belong  here. 

In  scarlet  fever  laryngitis  occurs  less  frequently. 
The  catarrhal  inflammation  presents  no  special  features. 
The  diphtheritic  form  is  more  common  (see  p.  43). 

In  Stnall-pox  the  larynx  is  often,  if  not  always,  in- 
volved. The  clinical  picture,  which  is  that  of  simple 
catarrh,  frequently  presents  a  specific  discoloration  from 
the  presence  of  small,  whitish  prominences  which  indicate 
circumscribed  epithelial  necroses.  If  they  increase  in 
size  and  prominence,  a  certain  similarity  to  skin-pustules 
is  suggested,  although  not  histologically,  since  they  never 
extend  beyond  the  epithelium.  Pus-collections  also  occur 
under  the  epithelium,  but  only  in  the  submucous  layer, 
and  must  therefore  be  regarded  as  pustules  rather  than  as 
true  abscesses.  After  the  loss  of  the  epithelial  covering, 
the  latter,  like  superficial  necroses,  result  in  erosions  or  in 
true  ulcers,  which  do  not,  however,  possess  any  typical 
features.  The  appearance  of  all  these  exanthemata  be- 
comes modified  in  "  black  "  small-pox  by  the  characteris- 
tic hemorrhages.  Either  as  the  last  stage  of  the  process, 
or  in  the  early  stages,  we  may  get  the  typical  diphtheroid 
appearance  of  the  larynx,  in  which  the  exudate  forms  a 
membrane  of  mingled  fibrin  and  blood  ;  the  external  ap- 
pearances and  clinical  consequences  are  the  same  as  in 
diphtheria. 


56  PATHOLOGY  AND  TREATMENT. 

The  marked  inflammatory  appearances  in  the  submu- 
cosa  and  perichondrium  have  no  specific  character. 

Typhoid  fever  affects  the  larynx  l)y  direct  deposition 
of  the  specific  bacilli.  Catarrh  develops  in  the  infiltra- 
tion stage ;  the  epithelium  is  attacked  and  readily  sepa- 
rates, exposing  the  surface  to  superficial  ulceration  and 
slight  hemorrhages.  The  specific  character  shows  itself 
in  the  cirGumscribed  nature  of  the  invasions,  particularly 
at  the  aperture  and  at  the  vocal  processes.  The  erosions 
preferably  select  the  sharp  edge  of  the  epiglottis.  In 
analogy  with  the  intestinal  process  we  further  get  diffuse 
or  circumscribed  ^'  marrow "  infiltrations  and  secondary 
infiltration  resembling  the  intestinal  form.  Ulceration  is 
occasionally  preceded  by  a  definite  scaly  stage,  in  the  form 
of  diphtheritic  membranes.  If  the  ulceration  extends  to 
the  perichondrium,  perichondritis  with  all  its  evil  conse- 
quences ensues.  According  to  the  degree  of  intensity, 
the  parts  either  heal  completely,  or  grave  defects,  tightly 
drawn  scars,  membranous  and  other  stenoses,  remain 
(Plate  17,  Fig.  2).  In  exanthematous  typhoid  the  phe- 
nomena are  similar,  but  milder. 

In  the  treatment  we  must  always  take  the  laryngeal 
complications  into  account.  By  keeping  the  upper  parts 
of  the  alimentary  and  respiratory  passages  clean  we  may 
hope  to  influence  the  process  favorably.  Local  treatment 
accomplishes  nothing.  Stenoses  demand  early  trache- 
otomy, as  the  unexpected  ajjpearance  of  secondary  edema 
is  particularly  common  in  this  complication. 

Influenija  attacks  every  part  of  the  respiratory  tract. 
In  the  larynx  the  interarytenoidal  mucous  membrane  is 
often  found  to  be  inflamed,  and  therefore  (sec  p.  19)  we 
have  barking,  dry,  convulsive  cough,  resembling  and 
sometimes  mistaken  for  whooping-cough.  There  is  a 
marked  tendency  to  hemorrhage,  and  su])erficial  epithelial 
necrosis  appears  in  the  form  of  white  spots  on  the  true 
vocal  cords  ;  these  result  in  small  erosions.  In  rare  cases 
interstitial  inflammations  running  on  to  abscess-formation 
have  been  observed.     The  predilection  of  influenza  for 


ACUTE  INFLAMMATIONS.  57 

the  nervous  system  sometimes  shows  itself  in  affections  of 
the  recurrent  nerves.  All  these  lesions,  however,  tend  to 
heal  of  themselves. 

The  treatment  is  purely  symptomatic,  and  consists 
principally  in  rest.  Graver  complications  demand  the 
usual  interference. 

The  general  infection  known  as  herpes  in  very  rare 
instances  becomes  localized  in  the  larynx,  and  may  or 
may  not  be  preceded  by  previous  disease  in  the  mouth 
and  fauces.  The  patient  feels  very  sick  and  has  shaking- 
chills  ;  soon  very  minute,  clear  vesicles  appear  arranged 
in  groups  on  one  or  both  sides  of  the  larynx,  usually  at 
the  aperture  only.  The  epithelium  rapidly  separates  and 
the  vesicles  are  converted  into  small,  flat  ulcers  with 
sharp  outlines,  covered  with  a  layer  of  white  or  yellow 
secretion,  so  that  usually  ulcers  only  are  seen  (Plate  6, 
Fig.  1).  The  pain  is  violent  and  burning,  both  spontane- 
ous and  on  swallowing ;  the  voice  is  seldom  affected.  The 
duration  is  from  two  to  eight  days. 

Treatment  consists  in  ordering  complete  rest  and  very 
simple  diet.  The  pain  from  the  ulcers  is  often  so  great 
as  to  make  swallowing  impossible,  in  which  case  it  can  be 
allayed  by  carefully  touching  the  parts  with  nitrate  of 
silver  (see  p.  33). 

In  whooping"- cotlg^h  the  laryngeal  complications  are 
chiefly  mechanical.  In  the  stage  characterized  by  re- 
peated paroxysms  the  constant  irritation  betrays  itself  by 
a  redness  of  the  anterior  surface  of  the  posterior  wall ; 
the  expiratory  blast  is  unable  to  remove  the  scanty  secre- 
tion. Ecchymoses,  and  even  extensive  hematomata,  occur 
in  the  laryngeal,  as  in  other  mucous  membranes.  Local 
treatment  is  of  no  avail. 

The  most  important  acute  infectious  inflammation  is 
that  which  occurs  in  the  secondary  stage  of  Syphilis. 
The  first  and  mildest  manifestation,  a  diffuse  erythema, 
can  be  distinguished  from  benign  catarrh  only  by  the 
anamnesis  and  the  absence  of  any  known  cause.  JSTo thing 
but  the  subsequent  appearance  of  specific  signs  will  serve 


58  PATHOLOGY  AND  TREATMENT. 

to  distinguish  it  from  the  catarrhal  condition  to  which 
syphilitic  subjects  are  particularly  liable  after  an  eruption, 
and  ^vhich  justifies  the  warning  against  catching  cold 
during  treatment  with  unguents.  Perhaps  the  only  ex- 
ternal characters  of  syphilitic  erythema  are  found  in  a 
certain  velvety  quality  and  looseness  of  the  mucous  mem- 
brane and  in  a  graver  interference  with  phonation  than 
would  be  inferred  from  the  appearance  of  the  surface.  If 
a  specific  form  is  really  present  in  a  given  case,  the  char- 
acteristic signs  soon  make  their  appearance  :  the  mucous 
membrane  papilla  develops.  The  red  background  is  over- 
shadowed by  a  delicate,  bluish-white  veil  covering  the 
redness,  now  in  definite  circumscribed  areas,  again  in  iso- 
lated whitish  spots  (Plate  11,  Fig.  2).  The  discolorations 
rest  on  a  swollen  base  and  sometimes  occupy  the  greater 
part  of  the  larynx.  At  other  times  the  papilla  appears 
without  these  fijrerunners ;  it  is  then  usually  isolated,  also 
in  the  form  of  a  whitish  eminence,  but  surrounded  by  a 
zone  of  intense  inflammation  (Plate  12,  Fig.  1). 

The  appearance  is  often  so  characteristic  as  to  afford  a 
diagnosis  in  itself.  The  cervical  glands  are  invariably 
swollen,  and  traces  of  other  secondary  eruptions  in  the 
infected  region  are  rarely  wanting.  Until  the  papulae  are 
plainly  made  out,  however,  there  is  danger  of  confound- 
ing the  condition  with  catarrhal  erosions. 

The  general  treatment  must  be  supplemented  by  local 
measures  (the  author  has  found  internal  doses  of  hydrarg. 
chlor.  mit.  0.1,  opii  pur.  0.01,  t.  i.  d.  in  milk,  very  effec- 
tive whenever  the  use  of  unguents  was  impossible).  Ener- 
getic cauterization  of  the  papulae  with  nitrate  of  silver  or 
chromic  acid  (caution  !)  fused  upon  the  end  of  a  probe,  to 
be  repeated  once  or  twice  after  the  scab  has  come  away, 
is  very  efll.'ctive  not  only  to  liasten  recovery,  but  even 
more  to  allay  the  violent  pain  which  accompanies  and  in- 
hibits the  act  of  deglutition. 

The  prognosis  is  good.  Xeglected  cases,  it  is  true,  tend 
to  interstitial  proliferation  and  to  the  production  of  per- 


CHRONIC  INFLAMMATIONS.  69 

manent  post-syphilitic  hyperplasi?e  (Plate  14,  Fig.  1). 
Their  treatment  must  be  purely  surgical. 

The  rarest  complications  occur  in  connection  with 
acute  articular  rheumatism.  Violent  pain  in  the 
visible  and  palpable  cartilages,  with  swelling  of  the  con- 
nective tissue,  sometimes  even  a  thickening  of  the  cartil- 
age, appears  to  indicate  that  the  joints  of  the  larynx  occa- 
sionally share  the  fate  of  other  joints  in  the  body.  Of 
course,  if  attacks  of  acute  articular  rheumatism  are  fol- 
lowed by  motile  disturbances  (fixations  or  irregular  inter- 
ference with  the  excursions  of  the  true  vocal  cords),  we 
may  unhesitatingly  regard  them  as  sequelae  of  such  severe 
articular  inflammations. 

In  the  acute  stage  the  general  treatment  may  be  supple- 
mented by  local  cathartic  measures  (ung.  hydr.  applied  to 
the  throat  in  small  quantities  and  a  warm,  moist  bandage) ; 
later,  electrical  excitation  and  massage  of  the  muscles  may 
be  appropriate. 


II.  CHRONIC   INFLAMMATIONS. 

1.    THE    SUPERFICIAL   FORM. 

The  primary  forms  arise  either  from  acute  beginnings 
or  as  the  result  of  repeated,  though  slight,  irritation,  such 
as  violent  crying,  prolonged  exertion  of  the  voice  in 
speaking,  excessive  smoking,  singing  in  unsuitable  pos- 
tures, inhalation  of  dust,  especially  of  a  chemical  nature, 
etc.  The  symptoms  consist  in  moderate  hoarseness  or  a 
rough,  rasping  voice,  slight  cough,  and  scanty  expectora- 
tion of  grayish  mucus  streaked  with  dust  or  other  impuri- 
ties. A  dusky-red  hue  is  observed  over  the  entire  larynx, 
or  only  in  the  parts  about  the  true  vocal  cords ;  the  latter 
are  often  slightly  thickened,  and  slow  and  incomplete  in 
their  closure  upon  phonation.  Occasionally  circumscribed 
areas  of  hyperplastic  tissue  make  their  appearance,  and 
rapidly  disappear  again  as  soon  as  the  above-mentioned 


60  PATHOLOGY  AND  TREATMENT. 

causes  are  removed,  thus  explaining  their  origin.  The 
treatment  nuist,  therefore,  be  especially  directed  against 
these  adverse  influences  ;  rest  should  be  insisted  on  and 
voice-use  greatly  restricted.  The  inflammation  meanwhile 
may  be  combated  with  applications  of  nitrate  of  silver  (2-5 
per  cent,  sol.),  and,  if  there  are  hypertrophies,  with  ich- 
thyol  solution  (see  p.  33).  If  there  is  great  sensibility  of 
the  mucous  membrane  Avith  a  tendency  to  hemorrhage, 
the  local  treatment  must  be  limited  to  dusting  with  alum 
1  :  10  sacch.  i\\h.  These  measures  are  to  be  repeated 
daily  at  first ;  later,  every  two  or  three  days.  The  func- 
tions of  the  digestive  tract  must  be  carefully  attended  to 
at  the  same  time. 

Secondary  forms  are  met  with  much  more  frequently. 
Nine-tenths  of  all  the  cases  may  be  regarded  as  sequelae 
of  nose  and  throat  disease.  The  constant  hawking  and 
scra])ing  so  common  in  most  of  these  troubles  are  very 
injurious  to  the  true  vocal  cords.  Another  source  of  in- 
jury to  the  cords  is  the  constant  dripping  of  pus  and 
nuicus,  which  gradually  find  their  way  from  the  arch  of 
the  palate  to  the  larynx  (where  a  layer  of  them  is  occa- 
sionally seen  in  the  interarytenoid  space)  and  moisten  the 
inner  surface.  This  secretion  acts  in  several  ways  :  first, 
by  direct  infection  ;  secondly,  by  maceration  ;  and,  finally, 
the  secretion  dries  and  sticks  fast,  tearing  off  ej)ithelial 
shreds  when  it  is  expelled  by  violent  coughing,  and  even 
giving  rise  to  hemorrhages,  which  in  turn  expose  the  sub- 
mucosa  to  infection. 

Another  cause  of  secondary  catarrh  is  found  in  syphil- 
itic infection.  Even  if  the  larynx  is  only  slightly  affected 
in  the  beginning,  it  l)ecomes  extremely  sensitive  to  ordi- 
nary adverse  influences;  hyperemias  of  long  duration  de- 
velop and  finally  lead  to  hyperjilasia  (Plate  14,  Fig.  1), 
or,  in  milder  cases,  to  ])ermanent  irritability  of  the  mucous 
membrane. 

Alcoholism  has  no  special  effect,  although  it  undoubt- 
edly exercises  an  indirect  influence  on  the  development  of 
the  disease,  inasmuch   as  catarrh  of  the  throat  is  very 


CHRONIC  INFLAMMATIONS.  61 

common  among  heavy  drinkers,  and  the  hawking  it  occa- 
sions acts  very  injuriously  on  the  larynx  ;  some  cases  are 
aggravated  })y  excessive  smoking,  the  usual  concomitant 
of  alcoholic  abuse.  The  piditre  of  the  secondary  affec- 
tion may  be  very  similar  to,  or  identical  with,  that  of 
primary  catarrh,  the  only  feature  which  is  at  all  charac- 
teristic being  the  accompanying  nasal  affection.  This  is 
usually  so  much  in  evidence  tliat  attem])ts  have  been 
made  to  class  it  as  a  special  disease,  forgetting  tliat  both 
forms  are  due  to  a  common  cause. 

In  one  case  we  may  see  a  pale,  slightly  granular  mucous 
membrane  after  closely  adherent  crusts  of  pus  have  been 
removed  by  coughing,  or,  when  necessary  on  account  of 
dyspnea,  by  direct  interference ;  the  true  and  false  vocal 
cords  narrowed  and  evidently  atrophic,  the  surface  of  the 
former  a  dirty  yellow  or  dotted  over  with  greenish  spots 
(Plate  10,  Fig.  3) — the  picture  of  so-called  laryngitis 
sicca.  In  another  case  the  prominent  feature  may  be 
hypertrophy  of  the  mucous  membrane,  especially  of  the 
epithelium,  giving  rise  to  wart-like  eminences  (Plate  22, 
Fig.  3);  again,  wheals  ap])ear  on  one  or  both  true  vocal 
cords,  presenting  by  certain  indentations,  which  corre- 
spond in  i)osition  to  the  points  where  they  are  firmly  at- 
tached to  the  cartilage  below,  and  by  the  formation  of 
ridges  from  the  reciprocal  pressure,  a  clinical  picture 
which  has  been  described  as  ^^  pachydermia  verrucosa," 
and,  with  small  show  of  reason,  classed  as  a  special  dis- 
ease (Plate  10,  Fig.  1).  In  addition  to  hyperplasia  and 
the  maceration  already  referred  to,  the  reaction  of  the 
epithelium  to  the  constant  irritation  may  sliow  itself  in 
hemorrhages,  brought  about  by  laceration  of  the  mucous 
membrane  as  the  secretion  is  coughed  up ;  these  hemor- 
rhages are  characteristically  foimd  associated  with  liyper- 
trophies  (Plate  10,  Fig.  1). 

The  prognosis  may  be  epitomized  in  the  maxim  :  Tin- 
manente  causa  non  cessahit  effectus.  The  fundamental 
principle  in  the  treatment  is,  therefore,  removal  of  the 
nose  and  throat  disease.     This  in  itself  often  suffices  to 


62  PATHOLOGY  AND   TREATMENT. 

bring  about  recovery.  If  the  primary  trouble  cannot  be 
got  rid  of  at  once,  it  should  at  least  be  kept  within  bounds 
as  much  as  possible  by  frequent  and  thorough  cleansing 
of  the  nasal  and  postnasal  cavities.  The  larynx  must 
also  be  treated ;  the  use  of  the  voice  must  be  absolutely 
prohibited  for  weeks ;  all  irritating  food  and  drink  must 
be  eschewed.  Ichthyol  applications  (p.  33)  are  very  good  ; 
large  hyperplasiae  may  be  treated  Avith  electrolysis,  or  re- 
moved with  the  curet,  snare,  etc.  It  is  hardly  necessary 
to  add  that  intemperance  must  be  combated  in  the  alco- 
holic, that  abdominal  plethora  must  be  removed,  and  that 
antisyphilitic  measures  must  be  resorted  to  if  necessary. 
The  last  direction,  of  course,  does  not  apply  to  affections 
of  a  clearly  postsyphilitic  nature. 

2.   INFLAMMATIONS   OF   THE   SUBMUCOSA 

are  rarelj  primary.  As  soon  as  the  causes  Avhich  we  have 
just  discussed  in  connection  with  chronic  superficial 
aifections  exert  a  deeper  eifect,  they  may  give  rise  to  in- 
terstitial infiltration,  and  later  to  sclerosis  and  hyper- 
plasia. 

/Secondary  forms  following  a  specific  infection  are  far 
more  common. 

Syphilis,  on  account  of  its  predilection  for  connective 
tissue,  plays  a  prominent  part ;  by  means  of  the  secondary 
disease  of  the  vessels  which  it  entails,  extensive  altera- 
tions are  often  brought  about  in  the  deeper  layers.  New 
growths  of  a  tough,  fibrous  nature  develop,  together  with 
active  superficial  proliferations  (Plate  5,  Figs.  1  and  3), 
either  at  once  or  after  more  or  less  tissue-destruction  has 
taken  place.  True  fibromata  may  be  simulated  in  tliis 
way.  The  subcordal  mucous  membrane  is  another  favor- 
ite seat  of  such  processes,  with  the  result  that  grave  sten- 
oses develop. 

The  same  locality  is  frecjuently  chosen  by  typhoid 
(Plate  17,  Fig.  2)/and  tuberculosis  also  occasionally 
produces   here   similar   convolutions   to   those   to  which 


CHRONIC  INFLAMMATIONS.  63 

it  gives  rise  in  the  interarytenoid  mucous  membrane 
(Plate  14,  Fig.  2). 

But  it  is  in  scleroma  that  we  find  this  disease,  syph- 
ilis, in  its  most  typical  form.  The  thick,  firm,  uneven, 
pale  swellings  and  the  extensive  cicatricial  contractions 
are  most  characteristic  of  this  disease,  which  practically 
attacks  the  submucosa  exclusively  and  inevitably  results 
in  grave  and  extensive  stenoses. 

£eprosy  also  shows  a  preference  for  the  connective 
tissues,  where  it  first  forms  hyperplastic  tubercles  and 
eventually  leaves  an  exceedingly  tough,  fibrous  growth 
productive  of  the  gravest  stenoses. 

The  treatment  in  most  cases  is  necessarily  mechanical. 
The  new  growths  must  be  destroyed  with  "fire  and  sword,^' 
either  from  within  or  after  thyreotomy ;  if  that  is  impos- 
sible, the  stenosis  must  be  combated  with  bougies  or  by 
means  of  intubation,  and,  if  necessary,  tracheotomy. 

3.    CHRONIC   INFLAMMATIONS   OF   THE   MUSCLES 

are  always  secondary,  so  far  as  our  present  knowledge 
goes.  We  really  have  very  little  positive  knowledge; 
even  those  tuberculous  infiltrations  of  the  muscles  which 
are  sometimes  the  first  visible  signs  of  the  infection  are 
but  imperfectly  understood.  So-called  atony  of  the  true 
vocal  cords,  especially  if  unilateral  or  otherwise  isolated, 
is  probably  to  be  explained  in  this  way  (Plate  9,  Fig.  2). 
In  tuberculosis  there  is  probably  a  toxic  degeneration  of 
the  muscle-substance ;  trichinosis  attacks  the  muscle 
directly. 

We  can,  of  course,  readily  understand  that  the  muscu- 
lar tissues  should  be  involved  in  any  extensive  process  of 
infiltration  or  ulceration  of  whatsoever  description,  but 
the  fact  has  no  special  importance  except  in  affections  of 
the  abductors  of  the  vocal  cords  (see  below). 

4.  CHRONIC    INFLAMMATIONS    OF    THE   JOINTS 

are  more  easily  recognized.     They  are  practically  always 


64  PATHOLOGY  AND   TREATMENT. 

the  result  of  acute  iuflammatious  (see  p.  49) :  the  symp- 
toms are  similar,  ouly  not  quite  so  severe. 

Many  a  so-called  "  rheumatic  "  paralysis  of  the  recur- 
rent nerves  is,  in  fact,  nothing  but  an  ankylosis  of  the 
arytenoid  cartilage.  The  differential  diagnosis  will  be 
found  under  the  head  of  Hypokinesis. 

The  treatment  promises  very  little.  Electrical  stim- 
ulation of  the  muscular  activity  and  massage  of  the  artic- 
ular region  constitute  the  only  available  measures. 


0.    CHRONIC    INFLAMMATIONS    OF    THE    PERICHONDRIUM 

AND    CARTILAGES 

present  exactly  the  same  phenomena  as  the  acute  forms 
which  we  have  described,  and  to  which  we  therefore  refer 
the  reader  (p.  49).  The  symptoms  may  be  less  pronounced, 
or,  if  the  formation  of  sequestra  has  led  to  separation  of 
the  cartilages,  more  intense. 

In  regard  to  the  etiology,  it  must  be  added  that  both 
gout  and  arthritis  deformans  occasionally  form  deposits  in 
the  larynx  whose  true  nature  can  only  be  recognized  by 
their  intimate  relation  to  other  unmistakable  localizations. 
The  treatment  in  such  cases  can  only  be  general ;  occa- 
sionally, however,  the  gouty  foci  may  soften  and  eventu- 
ally demand  surgical  interference.  We  have  very  little 
knowledge  of  this  latter  process. 

6.    COMPLICATED  FORMS   OF   CHRONIC   INFLAMMATION. 
(a)  Tertiary  Syphilis  of  the  Larynx 

manifests  itself  in  diffuse  or  circumscribed  hifiUrations^  in 
swellinr/s,  and  in  ulcerations.  The  latter  appear  either  at 
once  or  after  tlie  two  first-named  conditions. 

The  diffuse  infiltration  is  seldom  limited  to  the  mucous 
membrane  ;  it  usually  j^cnetrates  tlie  submucosa  and  often 
extends  to  the  muscles  and  to  the  ])erichondrium,  as  is 
proved  by  the  marked  interference  with  movement  which 
occurs  very  early.     The  mucous  membrane  is  red  and 


CHRONIC  INFLAMMATIONS.  65 

velvety ;  the  normal  shape  is  masked  by  thick  convolu- 
tions more  or  less  clearly  outlined  against  the  surrounding 
parts  (Plate  13,  Fig.  1).  Purely  inflammatory  swelling 
and  edema  often  complicate  the  picture  (Plate  23,  Fig.  2). 
If  the  infiltrations  are  round  and  distinctly  separated 
from  the  healthy  tissue,  they  may  be  termed  gummata,  as 
in  other  parts  of  the  body  (Plate  4,  Fig.  1).  This  char- 
acter becomes  accentuated  if  they  are  elevated  above  the 
surface  and  form  true  sivellings  (Plate  18,  Fig.  3,  and 
Plate  22,  Fig.  2).  Histologically  such  swellings  are 
found  to  be  true  sypMlomafa  (Plate  41,  Fig.  2).  These 
appearances,  however,  do  not  persist  for  any  length  of 
time;  disintegration  early  supervenes,  and  we  get  the 
typical  ulcers  with  red,  steep,  clear-cut  ("punched-out^^) 
edges  and  a  greenish-gray  depression  (Plate  5,  Fig.  2j. 
Usually  the  two  conditions  are  seen  at  the  same  time. 

The  favorite  seat  is  the  ^superior  aperture  of  the  larynx, 
especially  the  epiglottis,  though  any  other  part  may  also 
be  involved.  The  principle  of  least  resistance  asserts 
itself  in  the  greatest  frequency  of  the  ulcers  on  the  true 
vocal  cords,  as  they  are  most  concerned  in  the  function  of 
the  organ,  and,  after  that,  on  the  lingual  surface  of  the 
epiglottis,  which  is  most  exposed  to  injury  from  ingested 
food  (chilling  and  over-heating)  and  to  infection  from  the 
mouth. 

In  the  first,  the  infiltration-stage,  the  course  is  treacher- 
ously sloiv.  The  deposit  may  accumulate  for  weeks  with- 
out betraying  its  nature  by  any  perceptible  characteristic 
signs.  The  patients  during  this  period  feel  so  little  dis- 
comfort that  they  rarely  present  themselves  for  examina- 
tion. In  most  cases  they  consult  a  physician  only  when 
they  begin  to  feel  serious  inconvenience,  w^hich  does  not 
occur  until  nearly  the  end  of  the  infiltration-stage  or  in 
the  beginning  of  degeneration.  Before  this  time — de- 
pending upon  the  seat  of  the  affection — the  voice  may 
have  become  impaired,  or  the  patient  may  have  felt  a 
dryness  and  ^^  scratchy  ^' feeling  in  the  throat;  but  now 
he  complains  of  pain,  usually  slight  but  sometimes  violent^ 
5 


66  PATHOLOGY  AND   TREATMENT. 

stabbing  and  burning  in  character  during  the  act  of  swal- 
lowing, after  sleeping,  and  also  in  speaking,  and  there  are 
marked  vocal  disturbances.  The  epiglottis  may  fail  to 
act  as  a  result  of  mechanical  interference,  and  there  may 
be  consequent  dysphagia. 

The  ulcerative  stage  is  succeeded  by  ciGatrization.  The 
original  marked  increase  of  connective  tissue  is  replaced 
by  a  corresponding  contraction ;  where  the  infiltration 
occupied  the  place  of  normal  parts  we  get  greatly  dimin- 
ished volume ;  and,  on  the  other  hand,  masses  of  tissue 
may  be  deposited  in  places  where  there  was  none  before. 
In  one  case  we  shall  have  defects  (Plate  4,  Fig.  3) ;  in  the 
other,  marked  cicatricial  contractions  and  membrane-for- 
mation (Plate  30,  Fig.  3). 

The  disease  does  not  always  end  with  the  effects  of 
syphilitic  infection  ;  mixed  infections  may  continue  their 
work  in  spite  of  antisyphilitic  treatment,  especially  in 
situations  unfavorable  to  the  elimination  of  the  morbid 
products — the  submucous  layer,  the  perichondrium,  and 
the  articulations ;  the  only  hope  then  lies  in  the  recupera- 
tive powers  of  the  organism  or  in  operative  interference. 
The  latter  is  to  be  considered  only  when  larger  necrosed 
particles — sequestra — are  to  be  eliminated  ;  their  presence 
is  often  an  indication  of  a  constant  or  recurring  reaction 
in  any  one  situation. 

Such  postsyphilitic  complications  following  the  specific 
cure  betray  themselves  by  persistent  swellings,  etc.,  some- 
times, too,  by  the  subsequent  recurrence  of  proliferation. 
The  former  condition  is  illustrated  in  Plate  13,  Fig.  3; 
the  latter,  in  Plate  5,  Figs.  1  and  3. 

The  difference  between  such  postsyphilitic  inflamma- 
tions and  specific  granulomata  is  best  seen  histologically  : 
Plate  40,  Fig.  2,  and  Plate  41,  Fig.  1,  represent  the  first 
variety,  secondary  wart-formations ;  while  Fig.  2  on 
Plate  41  shows  a  true  syphiloma. 

The  diagnosis  of  tertiary  disease  will  rarely  be  based 
on  the  findings  in  one  situation  only,  as,  for  instance,  in 
the  larynx ;   anamnesis,  other  accompanying  symptoms, 


CHRONIC  INFLAMMATIONS.  67 

and,  above  all,  remains  of  former  specific  disease  in  other 
parts  of  the  body,  must  be  taken  into  account.  The 
marked  inflammation  of  surrounding  structures  in  the 
active  stage,  the  painful  swelling  of  the  glands,  the 
smooth,  steep  edges  of  the  ulcers,  the  rapid  degeneration 
in  infiltration,  the  wide  extent  of  both  ulceration  and  in- 
filtration— all  these  factors  afford  valuable  signs  for  differ- 
entiation from  other  processes. 

The  duration  of  the  disease  and  the  condition  of  lungs 
and  character  of  sputum  serve  to  distinguish  it  from  tu- 
berculosis, while  malignant  growths  are  excluded  by  ob- 
serving the  advance  of  the  process  and  whether  the 
infiltration  degenerates  rapidly — above  all,  by  noting  the 
effect  of  antisyphilitic  treatment.  Hence  diagnosis  is 
often  arrived  at  ex  juvantlbus. 

It  is  eveii  more  difficult  to  recognize  postsi/phlUtic  pro- 
cesses as  such.  The  anamnesis  must  be  absolutely  posi- 
tive. It  is  to  be  remembered  that  they  are  very  common  ; 
many  a  stubborn  "  hypertrophic  catarrh,"  many  motile 
disturbances  described  as  "  nervous ''  or  paralytic,  are 
really  nothing  but  the  remains  of  earlier  infectious  pro- 
cesses. 

The  treatment  cannot  be  begun  too  early,  if  it  is  to  be 
effective.  Infiltrations  mav  show  no  chano'es  for  weeks, 
and  thus  deceive  the  practitioner  as  to  their  true  nature, 
whereas  they  can  be  reduced  by  therapeutic  measures. 
When  the  characteristic,  ulcerative  degeneration  has  once 
set  in,  its  progress  can  no  longer  be  arrested  ;  it  is  (simply) 
a  sign  that  necrosis  is  already  completed.  Hence  the  im- 
portance of  the  maxim,  ohstare  principlis. 

As  in  all  the  graver  forms  of  syphilis,  among  which 
laryngeal  syphilis  must  be  included  in  spite  of  its  com- 
parative infrequency,  iodid  of  potassium  alone,  especially 
in  small  doses,  sometimes  fails  to  act.  The  following 
mixture  is  recommended  : 


68  PATHOLOGY  AND  TREATMENT. 

^.  Sol.  pot.  iod.,  10.0  :  150.0  ; 

Sod.  carb.,  5.0 ; 

Syr.  cort.  aurant.,  25.0. — M. 

Sig.  One  tablespoonful  three  times  daily  before 
meals. 

This  should  be  supplemented,  if  possible,  by  unguents 
or  the  hypodermic  injection  of  a  mercurial  salt;  the 
author  prefers 

Hydrarg.  salicyl.,  1.0; 

Paraffin,  liquid.,  9.0. 

Sig.  One  Pravaz  syringeful  every  three  days. 

Local  treatment  is  required  only  in  complications  :  in 
the  mixed  infection  following  ulcerative  degeneration,  of 
course ;  and  in  sequelae  of  other  diseases  or  other  threat- 
ening symptoms. 

The  first  of  these — ulceration — may  be  effectively  com- 
bated by  cauterization  with  solid  nitrate  of  silver,  not  to 
be  repeated  until  after  the  scab  has  come  away ;  the  scab 
acts  as  a  bar  to  the  constant  infection  by  contact,  as  a 
means  of  removing  necrosed  tissue  more  quickly,  and  also 
as  a  protection  against  pain. 

Dyspnea  should  be  relieved,  if  possible,  by  mechanical 
means  :  scarification  of  infiltrated  parts,  removal  of  SAvell- 
ings,  and,  if  necessary,  tracheotomy. 

The  sequelae  are  sequestra,  the  discharge  of  which  is 
hastened  by  curettage,  but  may  sometimes  demand  thyre- 
otomy  ;  deep  abscesses,  which  must  be  opened  fi-om  witliin 
or  from  without ;  swellings,  which  must  be  removed  ; 
finally,  cicatricial  contractions  or  hyperplasi^e,  which  call 
for  mechanical  stretching  or  operative  removal. 

(b)  Tuberculosis  of  the  Larynx. 

Ktiology. — The  infection  may  invade  the  organ  pri- 
marily, as  it  does  practically  every  other  organ  in  the 
body,  but  is  more  often  secondary  to  disease  elsewhere. 


CHRONIC  INFLAMMATIONS.  69 

The  path  of  the  infection  is,  if  anything,  more  difficult  to 
explain  than  it  is  in  other  localities.  Either  it  traverses 
apparently  intact  or  injured  epithelium,  or  it  follows  the 
course  of  the  lymph-channels  :  the  former  is  most  likely  in 
the  diseases  secondary  to  pulmonary  phthisis ;  the  latter, 
in  the  forms  which  at  first  sight  appear  to  be  primary, 
but  are  in  reality  the  result  of  latent  disease  in  the  upper 
portions  of  the  respiratory  and  alimentary  tubes.  There 
is  no  doubt  that  diseased  cervical  glands  are  capable  of 
infecting  the  larynx ;  many  a  so-called  "  primary  ^'  case 
is  no  doubt  due  to  this  cause. 

Morbid  Anatomy. — The  principal  feature  is  the 
tuberculous  infiltration,  usually  showing  the  structure  of 
the  Schiippel-Langerhaus  tubercle  very  plainly,  some- 
times taking  the  form  of  irregular,  diffuse,  round-celled 
infiltration,  especially  about  the  vessels  and  glands.  The 
seat  of  predilection  is  the  middle  of  the  posterior  wall 
(Plate  19,  Fig.  3;  Plate  21,  Fig.  1),  by  reason  of  the 
loose  arrano^ement  of  the  tissue  and  the  accumulation  of 
(pulmonary)  sputum  in  that  locality.  Other  parts  are 
occasionally  attacked  first ;  the  epiglottis  less  frequently 
than  any  other.  Sometimes  the  infiltration  is  circum- 
scribed ;  at  others  very  extensive  both  in  width  and  in 
length.  The  reaction  of  neighboring  structures  is,  in 
general,  very  slight,  and  their  resistance  proportionately 
feeble.  If,  however,  the  advance  of  the  infection  is 
checked  before  it  has  reached  the  deeper  layers,  we  get 
the  lupoid  form  of  the  disease,  characterized  by  numerous 
protuberances  in  the  infiltration,  a  very  slow  progress,  and 
showing  histologically  marked  reactionary  proliferation  of 
epithelium. 

If,  on  the  other  hand,  the  process  continues,  the  infil- 
tration soon  undergoes  necrosis,  forming  ulcers  on  the 
surface  and  hard  or  soft  sequestra  in  the  deeper  layers 
(Plate  12,  Fig.  2 ;  Plate  20 ;  Plate  21,  Fig.  2 ;  Plate  29). 

The  first  condition  opens  the  way  for  a  mixed  infection, 
although  (infective)  reaction  may  in  rare  instances  be 
strong  enough  to  drive  out  the  focus  of  the  disease.     De- 


70  PATHOLOGY  AND  TREATMENT. 

generation  is  more  likely  to  occur  where  function  has  be- 
come impaired,  the  infiltration  extending  far  beyond  the 
limits  of  the  visible  ulcer  (Plate  20). 

In  some  cases  the  tubercle-formation  proceeds  for  a 
long  time  within  the  deep  layers,  and  occasionally  gives 
rise  to  non-specific  proliferations  in  the  epithelial  and 
mucous  layers.  These  appear  as  swellings  and  are  usu- 
ally found  to  consist  also  of  diseased  tissue.  The  pro- 
liferations may  lead  to  the  formation  of  actual  tumors, 
their  true  nature  being  masked  by  the  intact  appearance 
of  the  surface  and  the  presence  of  a  pedicle  (Plate  21, 
Fig.  2;  Plate  21,  Fig.  1;  Plate  26,  Fig.   2;  Plate  28, 

If  the  perichondrium  is  more  extensively  invaded, 
there  result  edematous  swellings,  and  later  necroses,  pre- 
fera])lv  in  the  cricoid  and  arytenoid  cartilages,  correspond- 
ing to  the  most  frequent  localization  in  the  mucous  mem- 
brane of  the  posterior  Avail. 

All  these  various  anatomical  features  are  very  often 
blended  in  a  strange  ])icture  of  deformity  and  devastation. 

I/aryng"OSCOpic  Image. — In  the  initial  stages  we 
often  see  round  or  pointed  eminences  projecting  from  the 
interarvtenoidean  region,  beneath  which  ulceration  may 
liave  already  begun.  These  projections  are  usually  pale  ; 
in  fact,  the  entire  larynx  and  even  the  fauces  are  usually 
anemic  :  there  are,  however,  many  exceptions  to  this  rule. 
Sometimes  the  process  first  betrays  itself  by  paresis  or 
redness  of  one  or  both  true  vocal  cords.  These  also 
may  be  the  seat  of  slight  hypertrophies  and  excres- 
cences. If  the  infiltration  in  the  vocal  cords  breaks 
down,  we  see  discolored  yellow,  and  sometimes,  from  pro- 
trusion of  the  granulated  background,  reddish  erosions 
with  more  or  less  swollen  or  uneven  edges  (Plate  12,  Fig. 
2;  Plate  21,  Fig.  2).  The  decubital  action  of  the  other 
vocal  cord  leads  to  com]>lete  longitudinal  fission  of  the 
affected  one,  so  that  it  ajipears  to  be  divided  into  an  upper 
and  a  lower  half  (Plate  16,  Fig.  2). 

The  false  vocal  cords  are  usually  somewhat  thickened. 


CHRONIC  INFLAMMATIONS.  71 

and,  if  infiltration  is  present,  they  will  appear  to  be  nar- 
rowed (Plate  25,  Fig.  2). 

In  the  epiglottis  the  follieles  are  frequently  attacked, 
especially  at  the  edges,  and  soon  degenerate ;  the  extreme 
thinness  of  the  investing  membrane  there  often  gives  rise 
to  perichondritis  with  enormous  swellings  (Plate  6, 
Fig.  2). 

Tuberculomata  are  common  ;  they  are  recognized  by 
unmistakable  accompanying  symptoms  and  also  by  their 
general  appearance,  irregular,  uneven  surface,  and  broad 
base. 

The  diagnosis  is  often  quite  difficult.  The  first  thing 
to  bear  in  mind  is  that  tuberculosis  of  the  larynx  usually 
forms  only  a  part  of  a  general  process ;  but,  on  the  other 
hand,  it  must  not  be  forgotten  that  a  patient  may  have 
pidmonary  phthisis  and  laryngeal  syphilis  at  the  same 
time ;  in  fact,  the  two  diseases  have  even  been  observed 
in  the  larynx  at  the  same  time  (Plate  21,  Fig.  1). 

In  general,  tuberculous  deposits  in  the  larynx  are  char- 
acterized by  slow  development,  moderate  redness,  and 
uniform  extension  to  the  adjoining  tissue.  Tuberculous 
ulcers  are  distinguished  by  raised  and  slightly  papillary 
or  convoluted  edges ;  often  the  edges  alone  are  visible  in 
the  form  of  pointed  eminences  on  the  posterior  wall. 
This  phenomenon  is  so  frequent  in  the  early  stages  of  the 
disease  that  its  appearance  in  this  locality  has  been  con- 
sidered pathognomonic. 

Tubc^rculomata,  we  repeat,  are  recognized  by  their  broad 
base  and  uneven  surface ;  infiltrations,  by  their  rigidity 
and  pale  color.  Plain  as  all  these  phenomena  may  be  to 
the  eye  of  the  experienced,  a  combination  of  all,  or  of 
some  of  them,  which  is  usually  present,  will  materially 
facilitate  the  diagnosis,  especially  if  the  individual  forms 
are  atypical,  for  the  picture  is  often  greatly  altered  by 
mixed  infections  and  by  functional  irritation. 

It  is  absolutely  indispensable  to  collect  all  the  corrobo- 
rative evidence  possible  by  thorough  examination  of  the 
entire  body,  and  especially  of  the  lungs,  as  well  as  of  the 


72  PATHOLOGY  AND  TREATMENT. 

secretions  of  ulcers  and  of  extirpated  portions  of  swellings. 
In  obtaining  the  secretions  the  parts  must  be  previously 
cleansed  with  the  greatest  possible  care  to  guard  against 
contamination  with  lung-sputum.  The  course  of  the  dis- 
ease is  compared  with  that  of  syphilis,  carcinoma,  etc. ; 
sometimes  it  is  advisable  to  try  the  effect  of  antisyphilitic 
treatment.  In  general,  it  may  be  said  that  it  is  impossi- 
ble to  teach  anyone  theoretically  how  to  make  a  diagnosis 
from  the  picture  in  any  given  case,  because,  in  order  to 
arrive  at  a  decision,  one  must  first  learn  the  development 
of  many  successive  pictures  by  long  personal  observation. 
Not  the  picture  of  to-day,  but  that  of  yesterday  and  that 
of  to-morrow  must  decide  for  or  against  laryngeal  tuber- 
culosis. 

The  symptoms  are  vocal  disturbances,  often  very  early, 
due  to  degeneration  or  infiltration  of  the  muscles,  later  to 
alterations  in  the  mucous  membrane  of  the  vocal  cords  or 
of  the  interarytenoidean  space ;  in  inflammations,  particu- 
larly of  the  posterior  wall,  great  desire  to  cough ;  dys- 
phagia, due  to  ulceration  of  the  parts  concerned  in  func- 
tion ;  and,  finally,  dyspnea  in  cases  of  perichondritis,  ex- 
tensive infiltration,  and  large  tumors. 

The  treatment  is  strictly  divided  into  curative  and 
symptomatic  treatment. 

The  former  is  to  be  employed  in  all  cases  which,  from 
tlie  condition  of  the  lungs,  the  general  health,  and  the 
previous  course  of  the  disease,  promise  permanent,  com- 
plete recovery  after  the  laryngeal  trouble  shall  have  been 
removed.  Spontaneous  cure  of  the  local  affection  is  so 
rare  that  it  practically  need  not  be  taken  into  considera- 
tion. Tlie  curative  measures  are,  in  circumscribed  incipient 
infiltrations,  thorough  curettage,  and,  if  necessary,  destruc- 
tion of  the  base  with  the  cautery-needle  or  by  electrolysis  ; 
in  more  diffused  forms,  excision  witli  double  curet,  espe- 
cially on  the  upper  surface  of  the  posterior  wall ;  in  ulcer- 
ations, vigorous  scra])ing  and  painting  with  30-80  per 
cent,  solution  of  lactic  acid  ;  tumors  must  be  removed 
with  curet  or  galvanocautery.     If  the  extent  or  the  seat 


CHRONIC  INFLAMMATIONS.  73 

of  the  morbid  process  is  such  as  to  make  complete  ex- 
termination of  the  diseased  tissue  jper  vias  naturales  im- 
practicable, thyreotomy  should  be  practised,  and  be  followed 
up  with  a  thorough  cleansing.  It  is  advisable  to  examine 
the  wound  again  after  two  or  three  days,  as  important 
points  are  often  overlooked  during  the  operation  on  ac- 
count of  the  hemorrhage.  In  our  opinion,  extirpation  of 
the  larynx  is  not  practicable  even  in  very  extensive  dis- 
ease ;  partial  excision  of  diseased  cartilages,  on  the  other 
hand,  may  be  practised  with  good  results  in  chondro- 
perichondritis. 

The  symptomatic  treatment  must  be  employed  when  the 
condition  of  the  larynx  requires  interference  and  the  gen- 
eral condition  is  such  that  permanent  cure  or  even  lasting 
improvement  is  not  to  be  expected. 

Painful  ulcers  which  impede  deglutition  are  treated 
with  lactic  acid,  and,  if  the  underlying  infiltration  is  very 
extensive,  with  energetic  curettage ;  tumors  interfering 
with  respiration  must  be  removed  ;  perichondritic  abscesses 
must  be  drained ;  if  the  dyspnea  continues  and  cannot  be 
relieved  in  any  of  these  ways,  especially  if  it  is  due  to 
perichondritis  or  to  subcordal  abscess,  tracheotomy  must 
be  resorted  to.  This  operation  is  also  indicated  in  exten- 
sive ulcer-formations,  for  complete  rest  of  the  larynx  will 
do  much  to  lessen  the  pain  and  discomfort,  and  may  be 
followed  by  actual  improvement.  In  addition,  morphin 
should  be  freely  used  in  hopeless  cases,  remembering  that 
the  patient  cannot  in  any  case  live  long  enough  to  contract 
the  morphin-habit.  (We  say  nothing  here  of  general 
treatment,  such  as  is  required  in  tuberculosis.)  Inhala- 
tions of  balsamic  substances  may  be  employed  with  ad- 
vantage, if  only  to  cover  up  the  offensive  odor ;  their 
therapeutic  value  is  doubtful,  to  say  the  least.  Let  the 
patient  inhale  turpentine,  menthol,  Peruvian  balsam,  or 
ol.  pini  pumilionis  from  a  cotton  pledget  saturated  with 
any  of  these  substances  and  placed  in  the  bowl  of  a  clean 
earthenware  pipe,  or  the  drug  may  be  poured  on  hot  water 
and  the  vapor  inspired  through  a  paper  funnel. 


74  PATHOLOGY  AND   TREATMENT. 

For  general  treatment  we  will  emphasize  the  import- 
ance of  staying  in  a  quiet  place  where  the  air  is  free  from 
dust.  Whether  the  treatment  is  symptomatic  or  curative, 
talking  should  be  strictly  prohibited,  so  as  to  insure  abso- 
lute rest  for  the  organ.  In  conclusion,  let  it  be  remem- 
bered that  occasionally  the  symptomatic  treatment  has  the 
effect  of  a  curative  one,  agreeably  surprising  the  practi- 
tioner by  unexpected  recovery. 

(Cj  Leprosy  of  the  Larynx, 

although  only  a  rather  unusual  complication  of  a  general 
infection,  is  important  on  account  of  the  fatal  stenosis 
which  it  occasions.  The  rigid,  nodular  infiltration,  which 
is  quite  analogous  to  the  phenomena  in  the  skin,  encroaches 
upon  the  lumen  considerably,  and  the  condition  is  further 
aggravated  by  the  resulting  ulcers  and  cicatricial  contrac- 
tions. 

Mutilations  of  the  organ  from  extensive  tissue-destruc- 
tion, especially  in  the  epiglottis,  are  not  rare. 

The  diagnosis  is  very  simple,  as  the  disease  never  at- 
tac'ks  the  larynx  alone.  Tracheotomy  is  the  only  possible 
treatment. 

(d)  Scleroma 

is  more  commonly  seen  in  Germany.  Until  a  short  time 
ago  it  was  known  only  in  the  form  of  rhinoscleroma, 
which  is  suggestive  of  the  important  fact  in  the  diagnosis 
that  the  larynx  and  trachea  are  always  attacked  second- 
arily. The  same  charactei-istic  ])ale,  gristle-like,  wide- 
spread infiltrations  and  flat,  lumpy  ulcers,  covered  with 
dry  pus-scabs,  are  seen  as  in  the  nose.  The  subcordal 
space  is  ])articularly  liable  to  be  attacked,  so  that  we  see 
thick,  soft  wheals  projecting  into  the  lumen. 

In  doubtful  cases  the  diagnosis  is  made  certain  by  the 
presence  of  the  characteristic  bacteria  in  the  excised 
tissue. 

So  far  as  our  present  knowledge  goes,  any  attempt  to 


NEOPLASMS  OF  THE  LABYNX.  75 

combat  the  disease  is  hopeless;  tracheotomy  often  be- 
comes necessary. 

(ej  Gout  and  Arthritis  Deformans, 

according  to  some  observers,  furnish  a  few  cases  of 
chronic  inflammation  in  the  hirynx.  Gouty  deposits  are 
found  on  the  epiglottis  and  also  on  the  large  cartilages. 
The  mucous  membrane  bulges  out  in  broad  and  circum- 
scribed areas  and  possesses  a  conspicuous  light  yellowish- 
red  color ;  the  infiltration  is  hard  and  gritty.  Softening 
with  ulceration  is,  of  course,  possible  as  in  other  locali- 
ties. 

The  second  disease  attacks  the  joints  of  the  larynx  and 
gives  rise  to  motile  disturbances  (see  p.  51),  the  true  cause 
of  which,  as  in  gout,  can  only  be  determined  by  their 
close  relation  to  the  general  symptoms. 


III.  NEOPLASMS   OF  THE   LARYNX 

may  be  divided  into  homologous,  the  tissue  and  structure 
of  which  correspond  to  those  of  the  fundamental  tissue  or 
parts  of  it;  and  heterologous,  in  which  either  tissue  or 
structure  is  different,  giving  rise,  in  the  latter  contingency, 
to  an  atiipical  growth.  The  first  category  may  be  further 
divided  into  neoplasms  of  individual  tissues,  and  hyper- 
plasise  containing  several  or  all  the  histological  con- 
stituents. 

1.   HOMOLOGOUS   TUMORS. 
(a)  Neoplasms  of  Individual  Tissues. 

F'ibroma,  defined  as  a  pure  connective-tissue  tumor, 
associated  with  some  extension  of  the  epithelium  which 
is  only  secondary  and  does  not  attain  the  same  degree  of 
proliferation,  is,  in  reality,  very  rare,  although  the  diagnosis 


76  PATHOLOGY  AND  TREATMENT. 

of  fil)roma  is  often  made,  as  it  is  readily  confounded  with 
inflammatory  hyperplasiae. 

The  histological  constituents  of  the  tumor  are  chiefly 
fibrous  tissue,  a  few  (yellow)  elastic  fibers,  and  no  round 
cells,  or  only  a  few  on  the  surface,  probably  due  to 
mechanical  irritation. 

Edematous  and  mucous  degeneration  often  exists  in  the 
interior  witliout  materially  altering  the  character  of  the 
tumor.  If  the  process  goes  on  to  a  softening  of  the  tis- 
sues, they  may  be  completely  absorbed  and  a  cyst  may  be 
formed  (Plate  39,  Fig.  1). 

The  sff((t  of  the  tumor  varies ;  usually  it  is  in  the  looser 
parts  of  the  tissue ;  the  cvppearance  is  pale  to  light  red, 
sometimes  white  or  spotted  from  maceration  and  fatty  or 
horny  degeneration  of  the  epithelium  (Plate  31,  Fig.  2). 
The  surface  is  smooth  or  slightly  convokited,  or  it  may 
present  papillary  elevations  and  a  mulberry  outline,  as  is 
so  frequently  seen  in  the  nose.  It  is  then  termed  papillary 
fibroma. 

Fibroma  usually  occurs  in  middle-aged  men  (between 
thirty  and  fifty),  sometimes  much  later  in  life ;  it  is  per- 
fectly innocent. 

Chondromata  are  very  rare ;  they  are  really  ecchon- 
droses  of  the  laryngeal  cartilages,  causing  the  mucous 
membrane  to  bulge  out.     Their  origin  is  unknown. 

Adenomata. — We  know  them  only  in  the  form  of 
cysts,  due  to  dilated,  obsolete  glands.  Their  favorite  seat 
is  the  epiglottis,  where  they  may  be  so  large  as  to  interfere 
with  respiration. 

epithelioma. — This  term  may  be  applied  to  prolifer- 
ations of  the  epithelium  which  grow  toward  the  surface, 
and  in  which,  therefore,  the  ground-tissue  is  not  crowded 
aside  nor  involved  in  the  proliferation.  Such  isolated 
growths  are,  however,  very  rare  ;  an  example  is  seen  in 
Plate  34,  Fig.  3.  It  is  a  benign  growth  and  does  not 
recur  even  after  many  years. 

True  angiomata  arise  from  dilated  veins  or  capillaries. 
Plate  39,  Fig.  2,  shows  an  example  of  the  former  variety. 


NEOPLASMS  OF  THE  LARYNX.  77 

The  enormous  alveoli  are  included  in  a  slender  stroma  of 
fibrous^  partly  edematous  connective  tissue.  The  surface 
of  the  tumor  may  be  rough  or  smooth  ;  the  color  varies 
from  red  to  purple  (Plate  21,  Fig.  2) ;  the  volume  is  sub- 
ject to  variations.  They  are  much  given  to  internal  or 
external  bleedins;.  These  tumors  are  bv  no  means  com- 
mon ;  quite  often  the  ground-tissue  becomes  involved. 

The  lymphatics  occasionally  undergo  dilatation  to  the 
extent  of  forming  tumors.  I/ymphangiomata  then 
develop  either  from  simple  dilatation  or  from  proliferation 
of  the  vessel-\yalls ;  sometimes  they,  too,  lead  to  the  for- 
mation of  cysts.  They  usually  exhibit  hydropic  degener- 
ation of  tissue  in  certain  places.  In  their  external  appear- 
ance they  do  not  differ  materially  from  fibromata  or  from 
hyperplasi?e. 

Another  part  of  the  lymphatic  apparatus,  the  follicles, 
occasionally  degenerates  in  the  course  of  general  leukemia. 
The  favorite  seat  of  these  lymphomata  is  the  epiglottis, 
which  is  normally  very  rich  in  follicles  ;  they  are  also 
found  at  the  aperture  of  the  larynx.  They  appear  as 
whitish,  spherical  segments.  Tlieir  identification  (except 
by  microscopical  examination)  will  depend  on  other  locali- 
zations and  on  the  blood-count.  The  treatment  can  only 
be  general. 

Far  more  common  than  these  simple  structures  are 
mixed  tumors. 

(b)  Hyperplasia  of  Entire  Layers. 

l^tiology. — They  generally  originate  in  an  inflamma- 
tion, sometimes  obtained  from  the  anamnesis,  and  are 
characterized  anatomically  by  more  or  less  disease  in  the 
vessels.  The  latter  is  particularly  marked  in  syphilitic 
forms,  while  in  the  non-specific  hypertrophies  secondary 
to  tuberculosis  the  epithelial  proliferation  is  the  prominent 
feature.  In  view  of  this  constant  extraneous  origin,  the 
term  Secondary  Neoplasms  might  be  fitly  applied  to  this 


78  PATHOLOGY  AND   TREATMENT. 

group.  These  tumors  do  not  usually  attain  the  size  of 
those  described  above;  still  they  are  capable  of  producing 
grave  disturbances  in  both  phonation  and  respiration. 

We  may  further  subdivide  this  intrinsically  homogene- 
ous class,  if  not  by  clinical,  at  least  by  histological  char- 
acters, bearing  in  mind,  however,  that  the  various  subdi- 
visions are  essentially  alike. 

Fibro-epithelioina  is  the  most  frequent  form  ;  at  times 
proliferation  predominates  in  the  epithelium  (Plate  33, 
Fig.  3 ;  Plate  34,  Fig.  1),  at  others  in  the  connective 
tissue  (Plate  33,  Fig.  1);  while  in  a  third  class  of  cases 
the  overgrowth  is  uniform  in  both  (Plate  33,  Fig.  2 ; 
Plate  35,  Fig.  1  ;  Plate  40,  Fig.  2 ;  Plate  41,  Fig.  1). 

The  connective  tissue  is  more  or  less  rich  in  fibers, 
according  as  the  inflammatory  round-celled  infiltration  is 
more  or  less  prominent.  It  develops  preferably  about  the 
vessels,  forming  at  times  dense  conglomerations,  at  others 
long  streaks  under  the  epithelium,  or  the  fibers  may  be 
distributed  more  widely.  The  vessel-Avalls  (arteries)  them- 
selves are  often  affected ;  the  media  in  particular  reaches 
enormous  proportions,  although  intima  and  adventitia  also 
occasionally  constitute  the  most  conspicuous  features  of 
the  picture.  These  hypertrophies  of  the  vessel-walls  are 
always  most  pronounced  in  postsyphilitic  proliferations. 

The  veins  are  less  frequently  affected  ;  dilatation  is  met 
with  occasionally,  and  may  lead  to  the  formation  of 
angiomata  (Plate  33,  Fig.  1).  The  epithelium  really  fur- 
nishes the  typical  appearance  in  these  tumors,  notwith- 
standing its  overgrowth  is  only  a  secondary  phenomenon  ; 
nothing  could  be  more  conspicuous  than  its  excessive  pro- 
liferation. If  the  section  examined  is  too  superficial,  the 
inexperienced  may  even  be  led  to  suppose  cannnoma,  as 
the  far-reaching  projections  on  half  horizontal  section 
appear  completely  isolated  in  the  surrounding  tissue.  The 
picture  is  further  complicated  by  enormous  horny  excres- 
cences and  bv  fattv  and  colloid  dcofcnerations. 

If  the  blood-vessels  are  hypertrophied  either  in  the 
direction  of  their  axis  (Plate  40,  Fig.  1),  or  transversely 


NEOPLASMS  OF  THE  LARYNX.  79 

(Plate  39,  Fig.  3),  the  tumor  may  be  termed  an  angio- 
fibroma ;  overgrowths  of  the  lymphatics  (Plate  33,  Fig.  2) 
constitute  a  lymphangio-fibroma. 

If  the  glands  are  much  involved  in  the  proliferation, 
their  epithelium  degenerates,  and  we  get  colloid  tumors, 
which  may  lead  to  the  formation  of  cysts. 

The  most  interesting  of  these  neoplasms  are  the  jjapil- 
lary  forms.  T\\q  jjapillary  fibro-epithelioma  even  presents 
some  clinical  peculiarities.  The  histological  characters 
consist  in  branch-like  processes  of  connective  tissue,  ema- 
nating either  from  a  broad  base  parallel  to  the  surface,  or 
from  a  thick  stem,  covered  with  an  exceedingly  thick 
coating  of  epithelium.  Each  branch  is  supplied  by  a 
vascular  loop  containing  an  artery  and  a  vein.  Of  the 
origin  of  these  neoplasms  in  adults,  we  know  nothing ; 
the  theory  that  their  peculiar  forni  depends  upon  specific 
irritation  finds  much  support  in  the  fact  that  the  same 
tumors  in  children  are  unquestionably  due  to  acute  infec- 
tious processes  (like  measles  and  whooping-cough). 

These  tumors  also  exhibit  at  times  angiectatic  and  arte- 
ritic  phenomena,  as  well  as  round-celled  infiltration,  as 
signs  of  inflammatory  irritation. 

According  to  their  seat,  appearance,  and  clinical  behav- 
ior, the  tumors  of  this  group  have  received  various 
names,  without  regard  to  etiology  or  histological  classifica- 
tion. In  general,  their  seat  depends  on  the  kind  of  irri- 
tation to  which  they  are  due. 

Small,  hard  neoplasms  are  often  seen  on  the  free  edge 
of  the  vocal  cords  between  the  middle  and  anterior  thirds  ; 
they  are  called  singer's  nodules  (Plate  14,  Fig.  2 ;  Plate 
33,  Fig.  1).  In  this  situation  they  are  usually  caused  by 
excessive  functional  irritation.^ 

^  [The  theory  that  the  origin  of  these  nodules,  otherwise  known  as 
chnrditis  tuberosa,  is  due  solely  to  the  method  of  tone-production  termed 
"coup  de  glotte"  or  ''stroke  of  the  glottis,"  cannot  be  sustained.  They 
are  a  clinical  variety  of  pachydermia,  and  are  to  be  attributed  rather 
to  overuse  of  the  voice  than  to  merely  its  faulty  or  inartistic  use.  If 
the  singing  voice  is  accurately  "placed,"  or,  in  other  words,  if  the  direc- 
tion and  reinforcement  of  the  tone  are  proper,  the  mere  mode  of  attack 


80  PATHOLOGY  AXI)   TREATMENT. 

If  fibro-epitheliomata  develop  on  the  vocal  processes, 
they  often  take  the  form  of  cup-shaped  deposits  on  one 
side  and  wart-like  excrescences  on  the  other,  so  that  the 
latter  are  pressed  into  the  former  during  phonation.  The 
posterior  wall  presents  similar  dense,  flat  formations, 
either  in  connection  witli  the  former  or  independentlv 
(Plate  10,  Fig.  1  ;  Plate  16,  Fig.  1  ;  Plate  22,  Fig.  3j. 
On  account  of  the  altered  appearances  Mhich  are  the 
mechanical  result  of  this  localization,  observers  have  been 
led  to  describe  them  as  a  specific  disease  under  the  name 
of  pachydermia  larvngis.  For  the  etiology  of  this  variety 
of  irritative  hypertrophy  see  p.  60. 

Larger  neoplasms  of  this  kind  are  most  apt  to  be  found 
where  the  connective  tissue  is  loose,  and  may  look  exactly 
like  ordinary  fibromata  (Plate  31,  Fig.  1). 

If  portions  of  the  mucous  membrane  of  the  ventricles 
become  hypertrophied,  they  may  loosen  the  ground-tissue 
by  their  weight  to  such  a  degree  that  the  tumor  may  be 
moved  in  and  out  of  the  ventricle  either  with  a  probe  or 
by  the  movement  of  the  larynx  alone ;  we  thus  get  the 
picture  of  prolapse  of  the  ventricle  of  Morgagni  (Plate  18, 

The  proliferations  which  accompany  syphilis  and  tuber- 
culosis also  elect  the  seats  of  greatest  irritation,  either  in 
the  neighborhood  of  ulcers  or  over  infiltrations ;  if  they 
follow  in  the  wake  of  syphilis,  it  is  safe  to  assume  a 
hidden  inflammatory  focus,  though  it  may  remain  latent 
for  a  long  time. 

The  symptoms  of  homologous  tumors  are,  according 
to  the  situation,  dysphonia  (mufiled  or  peculiar  "gruff'' 
quality,  subdued  voice,  tem})orary  or  permanent  aphonia), 
occasionally  irritative  cough  with  reflex  spasms  of  the 
cords  (attacks  of  dyspnea),  and,  if  size  and  situation  are 
such  as  to  produce  it,  constant  dyspnea.  If  the  tumor  is 
movable,  the  symptoms  may  vary  a  good  deal  from  time 
to  time  and  a  new  symptom  may  arise :  a  rattling  noise, 

is  of  but  little,  if  any,  consequence  considered  in  its  relation  to  diseases 
or  injuries  of  the  vocal  cords. — Ed.] 


NEOPLASMS  OF  THE  LARYNX.  81 

heard  either  in  respiration  or  in  phonation,  and  caused  by 
the  striking  of  the  mass  against  the  walls  of  the  organ  as 
it  is  moved  by  the  current  of  air  (Plate  31,  Fig.  2). 

The  treatment  of  the  larger  tumors  consists  in  me- 
chanical removal ;  in  hypertrophies  special  attention  must 
be  paid  to  the  etiology,  if  they  are  to  be  successfully  exter- 
minated. If  the  irritation  is  functional,  smoking,  talking, 
singing,  or,  at  least,  incorrect  singing,  must  be  forbidden ; 
if  the  cause  lies  in  disease  of  nose  and  fauces,  it  must  be 
effectively  treated ;  any  foci  of  syphilitic  or  tuberculous 
infection  must  be  carefully  searched  for. 

It  is  to  be  remembered  that  the  papillary  forms  un- 
questionably originate  in  the  basal  connective  tissue,  al- 
though the  method  of  growth  is  unknown.  To  avoid  re- 
currence of  the  tumor,  the  tissue  in  question  must  there- 
fore be  extirpated.  In  papillary  tumors  with  broad  bases, 
especially  in  children,  the  operative  field  may  have  to  be 
laid  open  by  means  of  laryngotomy  in  order  to  accomplish 
this  end. 

We  need  not  here  go  into  the  technic  of  tumor- 
excision. 

2.   HETEROLOGOUS   NEOPLASMS. 

Two  kinds  of  tumors,  lipoma  and  struma,  are  types  of 
this  class. 

I/ipoma  occurs  in  the  form  of  broad,  deeply  lobulated 
tumors  with  finger-shaped  projections  in  places  where  the 
mucous  membrane  is  loosely  attached,  especially  at  the 
aperture  of  the  larynx.  They  rarely  develop  from  metas- 
tasis, and  must  be  attributed  to  fatty  degenerations  of 
fibromata. 

Tumors  consisting  of  thyroid-gland  tissue  sometimes 
spring  from  dislocated  portions  of  the  gland ;  that  is  to 
say,  a  malformation  (struma  accessoria).  They  are  cov- 
ered with  normal  mucous  membrane,  and  usually  are  of 
slow  growth.  They  must  not  be  confounded  with  true 
struma  bulging  into  the  pharynx  or  larynx  (Fig.  17). 

In  contrast  with  these  foreign  tumors  the  malignant 

6 


82        PATHOLOGY  AND   TREATMENT. 

growths  spring  from  normal  tissues,  and   only   become 
heterologous  through  their  atypical  growth. 

Carcinoma. 

Carcinotna  is  practically  always  primary. 

Of  the  origin  of  cancer  we  know  nothing  positive ; 
heredity,  no  doubt,  has  something  to  do  with  it.^  It  is 
also  known  that  syphilitic  and  other  ulcerations  may  set 
up  an  atypical  proliferation  of  the  epithelium.  The 
structure  is  usually  that  of  the  so-called  epithelial  cancer ; 
more  rarely  the  tumors  spring  from  the  glands.  Usually 
the  cancerous  growth  infiltrates  the  surrounding  tissues, 
which  remain  passive ;  in  rare  cases  (Plate  27,  Fig.  1  ; 
Plate  28,  Fig.  3)  the  connective  tissue  grows  so  as  to  form 
a  dense  pedicle  on  which  the  carcinoma  rests ;  sometimes 
the  connective  tissue  surrounds  the  invading  tumor  with  a 
network  of  dense  fibers  and  arrests  its  growth  (scirrhus). 

The  laryngoscopic  image  varies  greatly  ;  quite  often  the 
tumor  itself  cannot  be  seen,  and  all  that  appears  is  a  sec- 
ondary superficial  proliferation  of  benign  character,  caused 
by  the  irritation  in  the  deeper  layers.  Such  innocent 
tumors  may  exist  for  years  before  the  malignant  growth 
becomes  manifest,  and  this  has  given  rise  to  the  theory 
that  innocent  tumors  may  become  converted  into  car- 
cinoma. 

The  tumors  assume  the  most  variegated  forms :  in  one 
case,  multiple  papillary  proliferations  are  seen  on  the 
edges  of  the  vocal  cords ;  in  another,  a  general  metamor- 
phosis of  a  part  of  the  larvnx  into  rigid  knots  or  nodules 
(Plate  14,  Fig,  2),  or  a  flat  papillary  layer  (Plate  28, 
Fig.  1) ;  again,  a  rigid,  slightly  roughened,  widespread 
infiltration;  finally,  very  large,  lumpy  tumors  (Plate  17, 
Fig.  1).  As  the  process  goes  on,  the  tumor  always  breaks 
down,  and  the  combination  of  evident  neoplasm  with  the 

^  [So  far  from  increasing  his  belief  in  the  hereditary  tranbniis&ion 
of  cancer,  Herbert  Snow  says  that  his  experience  makes  iiim  the  more 
doubtful  of  the  malignant  nature  of  a  new  growth,  if  there  happens  to 
be  a  history  of  such  disease  in  the  patient's  ancestry. — Ed.] 


NEOPLASMS  OF  THE  LARYNX.  83 

signs  of  tissue-destruction  becomes  most  characteristic 
(Plate  28,  Fig.  1).  Sometimes,  however,  especially  in  the 
absence  of  secondary  proliferations,  the  centrally  located 
tumor  may  hide  itself  under  the  appearance  of  a  uniform 
s^Yelling  of  some  part  of  the  larynx,  especially  the  ven- 
tricular band.  Later  on  the  picture  is  complicated  by 
alterations  due  to  infection  of  the  ulcerated  portion?,  by 
edema  and  abscesses,  and  finally  by  necrosis  of  the  cartil- 
age after  the  perichondrium  has  become  absorbed.  A 
most  conspicuous  feature  is  the  early  interference  with 
function  ;  if  the  tumor  is  situated  on  the  true  vocal  cord 
or  near  the  crico-arytenoid  articulation,  as  is  usually  the 
case,  motile  disturbances  (sluggish  action)  manifest  them- 
selves out  of  all  proportion  to  the  small  tumor  ^vhich  may 
be  visible ;  the  appearance  of  this  symptom  should  lead 
us  strongly  to  suspect  cancer. 

Metastases  into  the  glands  usually  occur  very  late ; 
sometimes  they  far  surpass  the  original  tumor  in  extent.^ 

The  diagnosis  can  be  made  without  much  trouble  in  the 
advanced  stages  by  the  characteristics  just  enumerated ; 
in  the  early  stage  it  may  sometimes  be  suggested  by  the 
last-named  symptom.  Any  marked  subjective  symptom 
where  little  objective  alteration  is  visible  must  be  looked 
upon  with  suspicion.  Pronounced  sensibility,  periodic 
hemorrhages,  or  obstinate  hoarseness,  the  smallest  uni- 
latei^al  proliferation  or  infiltration  that  cannot  be  easily 
accounted  for,  in  patients  over  forty  years  of  age,  are 
most  suspicious  signs  of  cancer.  The  diagnosis  is  con- 
firmed by  clinical  observation  or  microscopic  examination. 
In  elderly  people  the  rigidity  which  has  been  mentioned 
almost  suffices  for  the  diagnosis.     In  obscure  cases,  if  the 

^  [The  time  at  whicli  secondary  infiltration  of  the  neighboring  lym- 
phatic glands  occurs  varies  with  the  situation  of  the  primary  growth. 
Krishaber,  Butiin,  and  others  classify  malignant  growths  of  the  larynx 
into  extrinsic  and  intrinsic.  The  former  include  those  involving  the  epi- 
glottis, arytenoids,  aryepiglottic  folds,  and  pyriform  sinuses,  and  the 
latter  those  affecting  the  vocal  cords  and  ventricular  bands,  and  the 
infraglottic  growths.  It  is  the  extrinsic  which  earliest  lead  to  secondary 
adenopathies. — Ed.] 


84  PATHOLOGY  AND  TREATMENT. 

presence  of  some  kind  of  tumor  is  evident,  the  diagnosis 
of  cancer  is  confirmed  by  the  results  of  continued  obser- 
vation, such  as  :  rapid  growth,  increased  pain  and  dis- 
comfort, and  rapid  recurrence  of  superficial  portions  of 
the  tumor  after  excision,  even  when  the  microscopic  ex- 
amination gives  a  negative  result. 

In  the  early  stages  microscopic  examination  is  not 
always  decisive,  as  the  real  tumor  may  be  seated  far  below 
the  surface.  If  the  changes  in  the  latter  are  not  advanced 
enough  for  a  vertical  section  to  exhibit  distinct  carcinom- 
atous characters  (epithelial  outgrowths  and  cancer-nests 
pervading  normal  or  newly  formed  tissue),  it  becomes  our 
duty,  as  well  as  our  right,  to  secure  deeper-lying  portions 
for  examination,  even  if  it  should  necessitate  performing 
thyreotomy. 

Such  an  exploratory  operation  in  the  early  stages  (pro- 
viding, of  course,  there  are  strong  grounds  for  suspecting 
cancer)  is  the  more  justifiable,  as  it  is  frequently  followed 
by  complete  recovery. 

In  doubtful  cases,  even  if  there  are  no  indications  of 
syphilis,  it  is  always  well  to  try  potassium  iodid  ;  it  is 
astonishing  what  good  results  sometimes  follow  the  exhi- 
bition of  this  drug.  Tuberculosis  of  the  larynx  in  the 
advanced  stages  is  also  a  frequent  source  of  error  (Plate 
28,  Fig.  2) ;  this  mistake  is  not  so  fatal,  however,  as 
failure  to  recognize  curable  syphilis  or  the  early,  operative 
stage  of  cancer. 

The  only  treatment  is  total  excision  of  the  tumor  with 
a  surrounding  zone  of  healthy  tissue.  If  the  diagnosis  is 
made  earlv,  this  can  usually  be  done  bv  means  of  larvn- 
gotomy  ;  the  prognosis  is,  of  course,  much  better  if  the 
process  is  circumscribed  than  in  extensive  disease  neces- 
sitating partial  or  total  extirpation.  The  fiite  of  cases 
not  operated  on  is  sad  indeed — death  from  asphyxia,  dys- 
phagia, or  sepsis. 

One  of  the  forms  of  papillary  fibroma  deserves  mention 
on  account  of  its  tendency  to  atypical  growth ;  it  is  the 
very  rare 


NEOPLASMS  OF  THE  LARYNX.  85 

Destructive  Papillary  Fibro=epithelioina. 

It  is  a  papillary  ("  Brussels  sprouts  ")  tumor  which  is  ex- 
ceedingly prone  to  recur  in  loco  after  removal^  and  even 
carries  its  infection  by  leaping^  as  it  were^  to  other  parts 
of  the  mucous  membrane.  The  first  characteristics  can 
be  explained  on  histological  grounds  ;  the  epithelial  masses 
spread  not  only  about  and  into  the  ne^Yly  formed  connec- 
tive tissue^  but^  also^  to  the  basal  tissue  and  even  into  the 
glandular  layer  (Plate  36,  Figs.  1  and  2).  Even  here, 
however,  the  connective  tissue  seems  to  play  the  principal 
part,  on  the  one  hand,  by  throwing  out  processes,  on 
the  other,  by  drawing  the  epithelium  down  with  it  into 
the  deeper  layers.  More  advanced  cases  are  needed  to 
throw  further  light  on  the  subject. 

Sarcoma 

in  the  larynx  probably  always  springs  from  the  endothe- 
lium or  from  the  adveutitia  of  blood-vessels  or  lymphatics. 
It  may  retain  the  alveolar  type  (Plate  37,  Figs.  1  and  2), 
or  it  may  diffuse  itself  into  the  adjacent  tissues ;  if  its 
origin  is  endothelial,  it  may  take  on  a  papillary  character 
by  proliferation  into  the  open  spaces  and  be  mistaken  for 
an  epithelial  tumor.  The  usual  varieties  occur  here  as 
elsewhere  :  medullary,  round-celled,  fibroid,  giant-celled, 
and  melanotic  sarcoma.  It  is  worth  noting  that  occasion- 
ally the  tumor  is  separated  from  the  healthy  tissue  by  a 
fibrous  stalk. 

Before  the  growth  breaks  through  to  the  surface,  it  is 
often  accompanied  by  excessive  proliferation  of  the  epi- 
thelium;  the  adjacent  connective  tissue  also  reacts  to  the 
irritation  bv  small-celled  non-heterologous  proliferations 
(Plate  37,  Fig.  1). 

As  regards  symptoms,  physical  characters,  metastasis, 
and  the  diagnosis,  sarcoma  is  essentially  the  same  as  car- 
cinoma. Possibly  the  sarcomata  are  distinguished  by  a 
more  uniform  surface. 

One  final  warning  for  the  diagnosis  seems  apposite  :  if, 


86  PATHOLOGY  AND  TREATMENT. 

in  examining  an  extirpated  portion  for  malignancy,  we 
think  only  of  cancer,  the  finding  of  epithelial  prolifera- 
tions— not  an  uncommon  occurrence  in  sarcoma — may 
cause  us  to  exclude  cancer  without  at  the  same  time 
awakening  a  suspicion  of  .sarcoma.  AVe  must  not  forget, 
therefore,  that  sarcoma  may  be  present  even  when  the  ex- 
amination gives  a  negative  result  for  cancer. 


IV.  DISTURBANCES   OF   MOTILITY. 

1.  MECHANICAL. 

Mechanical  disturbances  are  directly  due  to  muscula}- 
insufficiency.  These  develop  in  acute  and  chronic  inflam- 
mations and  infiltrations,  as  the  result  of  muscle-degener- 
ation in  general  tuberculosis,  in  trichinosis,  in  grave  an- 
emias, and  after  grave  acute  infections  (typhoid,  diphtheria, 
etc.) ;  also  from  overexertion  in  singing  and  speaking. 
The  diagnosis  is  based  on  typical  positions  of  the  vocal 
cords  during  phonation  or  respiration. 

Palsv  of  the  lateral  crico-arytenoid  muscle  causes  a 
gaping  of  the  glottis  cartilaginea  with  the  angle  formed 
by  the  two  cartilages  opening  forward  (p.  15,  Fig.  5), 
while  in  paralysis  of  the  transverse  arytenoid  muscle  the 
angle  of  divergence  looks  backward  (p.  15,  Fig.  4).  In 
paralysis  of  the  thyro-arytenoid  muscles  the  glottis  liga- 
mentosa  forms  a  semi-elliptical  or  elliptical  cleft  in  pho- 
nation, according  as  the  paralvsis  is  unilateral  or  bilateral 
(p.  16,  Fig.  6;  Plate  9,  Figs.  1  and  2).  If  the  lateral 
crico-arytenoid  muscle  is  affected  at  the  same  time,  this 
cleft  extends  to  the  cartilaginous  portion  ;  if  the  trans- 
verse arytenoid  is  involved  in  conjunction  with  the  thyro- 
arytenoids, a  double  ellipse  is  seen,  the  point  of  contact 
corresponding  to  the  apices  of  the  vocal  processes.  If 
all  three  muscles  are  paralyzed,  the  corresponding  vocal 
cord  is  arrested  in  respiratory  posture. 


DISTURBANCES  OF  MOTILITY.  87 

Paralysis  of  the  posterior  crico-arytenoid  muscle  pro- 
duces arrest  of  the  vocal  cord  in  respiration  at  or  very 
near  the  middle  line  (Figs.  21  and  22). 

The  symptoms  of  these  paralyses  are  (in  the  adductor 
group)  vocal  disturbances  running  on  to  complete  aphonia. 
In  rare  instances  the  ventricular  bands,  by  a  vicarious 
action,  arc  drawn  over  the  true  vocal  cords  (which  are  not 
sufficiently  adducted  or  stretched),  so  as  to  eifect  phona- 
tion ;  the  result  is  a  rough,  rumbling  voice  (Plate  3, 
Fig.  2).  Paralysis  of  the  posterior  crico-arytenoid,  if 
unilateral,  may  present  no  symptoms ;  bilateral  paralysis 
necessarily  produces  intense  dyspnea,  which  is  often  aggra- 
vated (in  unilateral  paralysis  produced)  by  perverse  con- 
traction of  the  adductors  brought  on  by  the  efforts  to 
overcome  the  dyspnea. 

The  treatment  must  be  cliiefly  directed  against  the  pri- 
mary trouble ;  in  addition  to  this,  direct  excitation  of  the 
muscles  by  electricity  from  within  or  without  may  be 
employed  with  advantage  (p.  35). 

That  inflammation  in  and  about  the  crico-arytenoid 
articulation  may  be  attended  by  motile  disturbances  has 
been  mentioned  (p.  49  et  seq.),  and  the  diagnosis  in  the 
active  stage  described  in  the  same  connection.  We  shall 
now  bring  out  those  points  which,  after  the  disappearance 
of  all  symptoms  referring  to  the  joint,  establish  with 
more  or  less  certainty  the  presence  of  an  articular  obstacle. 
It  is  quite  clear  that  all  such  phenomena  must  be  due  to 
diminished  passive  mobility. 

First,  we  would  mention  any  fixation  of  the  vocal  cords 
which  does  not  correspond  in  position  with  any  of  the 
muscular  paralyses  just  described,  or  with  the  nervous 
paralyses  to  be  described  in  the  next  section  ;  if,  for  in- 
stance, a  vocal  cord  assumes  a  position  midway  between 
that  of  the  cadaver  and  that  of  respiration  or  phonation, 
or  if,  during  phonation,  it  is  adducted  only  to  the  cadaveric 
position — if,  in  short,  its  excursions  are  incomplete.  Sec- 
ondly, the  jerky  movements  of  the  cords,  which  have 
been  mentioned,  as  if  they  were  being  dragged  over  ob- 


88  PATHOLOGY  AXD  TREATMENT. 

stacles.  In  addition,  we  have  those  cases  where  the  vocal 
cords  at  first  functionate  properly  enough  and  gradually 
become  more  and  more  sluggish  and  insufficient  in  their 
movements,  or  where  the  opposite  takes  place.  If  the 
motile  disturbances  alternate  in  position  between  adduc- 
tion and  aVjduction,  we  can  exclude  muscular  or  nervous 
paralysis  with  certainty.  Often  we  have  to  content  our- 
selves with  a  theory,  especially  when  the  condition  does 
not  present  fixation,  but  only  impeded  motion. 

2.   NEUROTIC  DISTURBANCES. 
(a)  Hyperkinetic  Neuroses. 

Both  tonic  and  clonic  spasms  occur  in  practically  all 
the  laryngeal  muscles. 

Tonic  spasms  of  the  abductors  have  a  central  origin  ; 
they  are  frequently  seen  in  tabes  dorsalis,  and  give  rise  to 
the  well-known  laryngeal  crises  :  sudden  attack  of  dyspnea 
with  loud  inspiration,  the  cords  often  remaining  fixed  in 
adduction  for  a  considerable  length  of  time ;  they  also 
occur  in  tetanus  and  in  tetany  and  occasionally  in  hydro- 
phobia 

Spasms  sometimes  proceed  from  the  timnJcs  of  the 
recurrent  nerves  as  forerunners  of  a  paralysis,  when  the 
causal  injury  is  slight  and  temporary  in  its  action. 

Reflex  adduction  forms  follow  direct  irritation  of  the 
larynx  or  even  of  the  mucous  membrane  of  the  fauces, 
by  therapeutic  applications,  by  the  entrance  of  foreign 
bodies,  or  by  the  aspiration  and  unintentional  swallowing 
of  intensely  irritating  materials  ("  irrespirable "  gases), 
and  by  tumors  in  or  near  the  larynx.  The  spasm  may 
also  be  excited  by  irritation  in  other  parts  of  the  body, 
especially  if  reflex  irritability  is  great.  This  is  always 
the  case  in  the  early  years  of  childhood — in  fact,  these 
spasms  are  so  frequent  and  so  dangerous  that  they  have 
been  described  as  a  special  disease  under  the  name  of 
laryngosjjasmus   infantum.      Nevertheless,    it   is    only    a 


DISTURBANCES  OF  MOTILITY.  89 

symptom,  not  a  disease,  and  may  be  due  to  the  most 
varied  causes.  If  it  cannot  be  referred  to  a  veiled  and 
obscure  tetany,  its  cause  is  usually  found  in  intestinal 
disturbances,  brought  on  by  artificial  foods  in  sucklings, 
by  intestinal  catarrh,  tape- worm  or  constipation  in  older 
children. 

Tonus  of  the  abductors  has  been  observed  in  hvdro- 
phobia.     The  vocal  cords  are  fixed  in  extreme  abduction. 

Clonic  Spasms  are  also  usually  seen  in  the  adductor 
muscles,  and  always  have  a  central  origin.  They  are 
characterized  by  a  rhythmical  tw^itching  inward  of  the 
vocal  cords,  sometimes  persisting  for  months.  Such 
spasms  have  been  observed  in  conjunction  with  similar 
ones  in  the  pillars  of  the  fauces,  on  one  or  both  sides,  in 
brain  syphilis,  after  meningitis,  direct  or  indirect  disease 
of  the  medulla  oblongata  in  the  neighborhood  of  the 
accessory  nucleus,  pressure  on  the  medulla  from  tumor  of 
the  cerebellum.  They  have  also  been  seen  in  paralysis 
agitans,  accompanying  the  tremulous  movements  of  the 
extremities — the  effect  probably  of  increased  irritability 
by  psychical   impressions. 

A  mixture  of  clonic  and  tonic  spasms  has  been  observed 
in  the  depressors  of  the  epiglottis ;  the  organ  would  sink 
dow^n  upon  the  aperture  for  variable  periods  of  time,  or 
merely  exhibit  slight  twitchings. 

The  treatment  of  spasms  of  central  origin  is  purely 
symptomatic,  as  the  primary  disease  is  usually  incurable. 
In  tabetic  crises  and  in  all  longer  attacks  it  is  best  to 
reduce  the  excitability  of  the  respective  centers  by  means 
of  morphin  injections,  especially  as  the  violent,  forced 
inspirations  only  tend  to  increase  the  dyspnea  by  sucking 
in  the  vocal  cords  and  the  epiglottis.  If  the  dyspnea  is 
prolonged,  tracheotomy  is  indicated. 

Spasm  of  the  glottis  in  children  endangers  life  and 
must  be  allayed ;  cold  douches  in  a  warm  bath  are  em- 
ployed with  good  success ;  the  etiological  factors  must,  of 
course,  be  looked  for  and  removed.  A  change  from 
artificial  food  to  the  breast  often  puts  an  effectual  stop  to 


90  PATHOLOGY  AND  TREATMENT. 

the  attacks.     Attention  must  be  given  to  the  functions  of 
the  gastro-intestinal  tract. 

(b)  Hypokinetic  Neuroses. 

Paralyses  or  pareses  affect  the  muscles  supplied  by  the 
superior  and  inferior  laryngeal  nerves.  Those  innervated 
by  the  recurrent  nerves  are  the  most  frequently  involved. 

The  picture  in  paralysis  of  the  recurrent  nerve  varies 
according  as  the  paralysis  is  unilateral  or  bilateral,  partial 
or  total. 

In  total  paralysis  the  affected  vocal  cord  is  fixed  mid- 
way between  respiration  and  phonation — the  so-called 
cadaveric  position.  We  regard  this  as  the  position  of 
passive  equilibrium,  as  neither  adductors  nor  abductors  are 
acting.  In  addition,  the  free  edge  of  the  vocal  cord 
appears  more  concave  than  usual,  showing  a  loss  of 
physiological  tonus  in  the  stretching  muscle  (Fig.  17);  if 
the  attack  is  prolonged,  the  muscle  atrophies  and  the 
vocal  cord  loses  in  width  (Plate  13,  Fig.  2).  The  aryte- 
noid cartilage  on  the  affected  side  projects  forward  (Figs. 
17,  18,  and  19). 

In  j)honation  one  vocal  cord  remains  immovable,  while 
the  other,  as  usual,  moves  to  the  middle  line  (Fig.  17),  and 
sometimes  beyond  it  as  a  compensation  (Fig.  18).  At  the 
same  time  the  arytenoid  cartilage  of  the  sound  side  is 
advanced  in  front  of  that  of  the  affected  side,  which  is 
pushed  aside ;  not  infrequently,  however,  the  latter  is 
seen  to  twitch  slightly  inward  and  forward,  as  the  trans- 
verse arytenoid  muscle  is  often  supplied  by  the  superior 
laryngeal  nerve,  instead  of  the  recurrent,  and  therefore 
retains  its  efficiency  even  in  paralysis  of  the  recurrent. 
As  this  movement,  when  present,  is  proof  of  the  passive 
mobility  of  the  articulation,  it  constitutes  a  reliable 
means  of  excluding  joint-disease.  The  epiglottis  is  also 
occasionally  seen  to  twitch  on  the  sound  side  whenever 
the  depressor  of  the  epiglottis  is  ''sup])lied  by  the  recur- 
rent instead  of  by  the  superior  laryngeal.     It  is  also  a 


DISTURBANCES  OF  MOTILITY.  91 

.certain  sign  that  the  lesion  is  nervous  and  not  articular. 
In  bilateral  paralysis  both  vocal  cords  remain  immovable 
in  the  cadaveric  position. 

The  symptoms  of  unilateral  paralysis  are  :  at  first  rough, 
feeble  voice,  later  somewhat  improved  through  compensa- 
tion ;  so  called  air- waste,  which  can  be  felt  by  the  hand 
held  over  the  mouth  as  superfluous  air  rushes  through  the 
excessive  cleft  of  the  glottis.  Bilateral  paralysis  pro- 
duces complete  aphonia.  A  want  of  vibration  in  the 
thyroid  cartilage  of  the  affected  side  is  not  without  signif- 
icance. In  the  beginning  we  sometimes  have  mis-swallow- 
ing, due  probably  to  paresis  of  the  epiglottis. 

Total  paralysis  is  always  preceded  by  partial  paralysis, 
although  the  latter  may  sometimes  escape  observation. 
It  is  confined  to  the  abductors,  so  that  the  pActure  shows 
one  or  Ijoth  vocal  cords  in  the  median  position  (Figs.  23 
and  24).  (The  arytenoid  cartilage  of  the  affected  side  is 
in  front  of  that  of  the  sound  side.)  The  reason  must 
be  sought  in  the  greater  vulnerability  of  the  abductor 
fibers. 

In  unilateral  median  posture  there  are  practically  no 
sympjtoms  ;  the  voice  is  good  and  respiration  is  not  impaired 
except  upon  great  exertion.  Bilateral  median  posture,  on 
the  other  hand,  interferes  seriously  with  respiration,  as 
the  respiratory  cleft  is  excessively  narrowed  (even  more 
than  is  shown  in  Fig.  22). 

Paralyses  originate  by  injury  to  the  centers,  to  the  vagus 
at  afiy  point  in  its  course,  or  to  the  recurrent  laryngeal 
itself. 

Central  paralyses  we  know  only  in  connection  with 
diseases  in  the  medulla  oblongata,  more  particularly  of 
the  accessoriovagal  nucleus.  Kothing  positive  is  known 
of  any  cortical  origin.  We  know  only  that  disease  about 
Broca^s  speaking-center  (left  inferior  frontal  convolution) 
mhWAi^  functional  movement  of  the  larynx. 

Positive  signs  of  a  central  paralysis  can  be  obtained 
only  by  a  general  examination  and  the  recognition  of  a 
general  disease,  or  by  other  symptoms  pointing  to  a  focus. 


92  PATHOLOGY  AND  TREATMENT. 

Among  the  known  causes  are  :  thrombotic  or  apoplectic 
softening  of  the  medulla  oblongata,  neoplasms,  abscesses, 
and  aneurysm  compressing  and  destroying  the  bulb,  dis- 
ease of  the  nuclei  in  the  medulla  (bulbar  paralysis),  lateral 
sclerosis,  progressive  muscular  atrophy,  syringomyelitis, 
and  tabes  cervicalis ;  finally,  general  nutritive  disturb- 
ances such  as  are  produced  by  syphilitic  disease  of  the 
blood-vessels.  It  goes  without  saying  that  the  diagnosis 
of  all  these  diseases  (which  we  will  not  go  into  here) 
must  be  established  before  it  can  be  made  use  of  as  an 
etiological  factor. 

Peripheral  palsies  follow  disease  of  the  vagus,  direct 
traumatic  or  operative  injury,  aneurysm  of  the  internal 
carotid,  malignant  tumors  on  the  base  of  the  brain,  in  the 
glands  or  in  the  mediastinum,  struma,  and  cervical  phleg- 
mon (purulent  neuritis). 

Any  one  of  these  causes  can  be  recognized  by  the  pulse- 
acceleration  which  always  accompanies  injury  in  this 
region  ;  if  the  paralysis  begins  above  the  origin  of  the 
superior  laryngeal  nerve,  the  latter  will,  of  course,  be 
involved  also,  and  eventually  the  paralysis  will  extend  to 
the  pharynx  (through  the  pharyngeal  branch).  Some- 
times the  pharynx  is  involved  in  paralysis  of  the  recur- 
rent alone,  probably  as  a  result  of  an  ascending  neuritis. 
In  most  cases  other  cerebral  nerves  are  paralyzed,  so  that 
we  often  get  the  picture  of  pseudobulbar  ])aralysis. 

Disease  of  the  recurrent  nerves  is  in  the  majority  of 
cases  caused  by  some  morbid  process  in  the  adjacent  tis- 
sues, and  is,  therefore,  an  important  factor  in  the  diagnosis 
of  such  lesions.  The  latter  include  :  aneurysm  of  the 
arch  (especially  for  the  left  nerve),  aneurysm  of  the  innom- 
inate artery  (for  the  right),  pericarditis  (left),  pleuritis 
of  the  apices  (more  right),  and  large  pleural  exudates ;  all 
the  diseases  of  the  mediastinal  tissues  and  of  the  medias- 
tinal glands  (carcinoma,  sarcoma,  tuberculosis,  syphilis, 
malignant  lymj)homa,  echinococcus,  etc.),  very  frequently 
g(^iter  (more  on  the  left  side),  and  cancer  of  the  esophagus 
(more  on  the  right  side);  rarely,  direct  injuries  (in  stru- 


DISTURBANCES  OF  MOTILITY.  93 

meotomy,  injections  into  the  parenchyma  of  a  goiter^  l^g^" 
tion  of  vessels). 

Infectious  neuritis  of  the  trunk  occurs  in  syphilis, 
diphtheria,  the  acute  exanthemata,  influenza,  pneumonia, 
and  typhoid  ;  toxic  neuritis  in  lead-poisoning  and,  per- 
haps, in  alcoholism.  A  "  rheumatic "  origin  is  very 
problematical. 

The  diagnosis  of  paralysis  of  the  vocal  cord  is  based  on 
the  laryngoscopic  image,  on  the  course  of  the  disease,  and 
on  the  exclusion  of  etiological  factors.  The  signs  of 
total  paralysis  of  the  recurrent  in  the  laryngoscopic  picture 
are  :  cadaveric  position  and  twitching  either  of  the  dis- 
eased arytenoid  cartilage,  or  of  the  sound  side  of  the 
epiglottis. 

A  median  position  is  shown  to  be  due  to  a  nerve-lesion 
by  the  subsequent  course  of  the  disease — that  is  to  say,  if 
it  is  followed  by  perfect  mobility  or  by  the  cadaveric 
position ;  conversely,  a  cadaveric  position  is  of  a  nervous 
nature  if  it  was  preceded  by  a  median  position. 

If  the  above  factors  are  not,  or  have  not  been,  present, 
we  cannot  at  once  decide  wdiether  a  fixation  of  one  or 
both  cords  is  due  to  paralysis  or  to  ankylosis.  We  must, 
before  making  a  diagnosis,  establish  the  existence  of  a 
central  or  peripheral  lesion  which  can  produce  paralysis, 
and  cannot  produce  mechanical  alterations  in  or  about  the 
joint.  For  instance,  struma  or  cancer  of  the  esophagus 
can  affect  the  nerve  only,  while  tuberculosis  and  syphilis 
can  affect  the  nerve  through  the  pleurae  or  the  glands,  and 
also  the  joint  either  directly  or  through  the  perichondrium. 
If  such  an  ambiguous  process  is  at  work,  paralysis  of  the 
recurrent  can  be  recognized  only  by  the  subsequent  course, 
or  if  the  laryngoscopic  image  is  unmistakable.  Other- 
wise the  diagnosis  had  best  be  left  open.  There  is  no 
doubt  that  the  cadaveric  position  in  so-called  rheumatic 
palsies  (w^hich  means  that  no  cause  can  be  found)  is  often 
due  to  mechanical  disturbances,  and  not  to  paralysis.  In 
the  absence  then  of  a  nervous  origin  and  of  unmistakable 
signs  in  the  course  of  the  disease,  or  of  a  characteristic 


94  •      PATHOLOGY  AND   TREATMENT. 

laryngeal  condition,  cadaveric  position  alone  cannot  be 
regarded  as  sufficient  proof  of  total,  nor  median  position 
of  partial  paralysis  of  the  recurrent. 

The  prognosis  of  paralysis  of  the  recurrent  is,  in  gen- 
eral, unfavorable,  as  most  of  the  causal  conditions  are 
incurable.  If  the  cause  can  be  removed,  as  in  goiter, 
syphilis,  etc.,  it  must  be  done  as  early  as  possible ;  partial 
paralysis  in  such  cases  disappears  without  further  trouble  ; 
but  if  the  paralysis  was  complete,  irreparable  atrophy  of 
nerves  and  muscles  (Plate  13,  Fig.  2),  or  at  least  abnormal 
movements,  may  be  the  result  (Fig.  25). 

The  treatme)d  must,  therefore,  be  directed  against  the 
primary  cause.  Local  applications  (internal  and  external 
electricity)  may  be  advisable  to  combat  the  muscular  in- 
activity ;  their  value  in  so-called  rheumatic  paralysis  is, 
of  course,  proportionate  to  the  problematical  nature  of 
that  condition. 

Paralyses  of  the  superior  laryngeal  nerves  are  of  very 
rare  occurrence.  They  manifest  themselves  by  inaction 
of  the  cricothyroid  muscle,  and  later  of  the  depressor  of 
the  epiglottis,  and  by  anesthesia  of  the  laryngeal  mucous 
membrane. 

The  first  lesion  relaxes  the  true  vocal  cords,  as  tlie  ten- 
sor muscles  can  no  longer  put  them  on  the  stretch  in  the 
absence  of  a  resisting  force ;  the  free  edges,  therefore, 
show  a  wavy  outline  (Fig.  23). 

If  the  cricoid  and  thyroid  cartilages  are  approximated 
mechanically,  the  voice  is  immediately  improved. 

The  paralysis  occurs  as  a  result  of  direct  injury  (opera- 
tive); more  frequently,  in  part  at  least,  as  a  sensory  paral- 
ysis after  diphtheria. 

Concerning  the  etiology  we  are  still  very  much  in  the 
dark. 

(c)  Parakinetic  Neuroses. 

This  term  is  applied  to  disturbances  of  innervation  in 
which  deviations  from  the  normal  movements  take  place. 

They  are  few  in  number,  and  may  be  divided  into 
organic  and  Junctional. 


DISTURBANCES  OF  MOTILITY.  95 

To  the  first  class  belong  the  disturbances  of  motility 
met  with  in  multiple  sclerosis  and  in  tabes.  In  the 
former  it  has  been  observed  that  the  vocal  cords  in  phona- 
tion  alternately  relax  and  contract  (intention-tremor) ; 
they  exhibit  fibrillar  twitehings  and  sluggish  closure  of 
the  glottis  ;  then^  in  inspiration^  the  glottis  is  closed  so 
that  the  inspirations  are  shrilly  especially  in  laughing. 
Sometimes  the  glottis  is  closed  by  a  spasmodic  movement 
in  phonation. 

In  tabes  the  vocal  cords  have  been  observed  to  move 
by  jerks  and  to  stop  half-way,  both  when  phonation  and 
inspiration  Avere  attempted,  constituting  therefore  a  true 
ataxia.  Similar  phenomena  have  been  observed  in  hemi- 
plegias, as  a  kind  of  fatigue-symptom. 

FundionaUy  aberrant  movements  in  the  opposite  direc- 
tion to  the  one  intended  are  quite  common  ;  they  must  all 
be  regarded  as  the  effects  of  perverse  innervation.  The 
latter  occurs  as  the  result  of  an  existing  paralysis,  oi  through 
physical  or  psychical  association-fatigue.  Thus  we  have  a 
convulsive  respiratory  closure  of  the  glottis  in  tabetic  or 
other  neurotic  median  position,  or  in  median  position  on  one 
side  and  cadaveric  position  on  the  other ;  also  in  the  so- 
called  respiratory  spasm  of  the  glottis,  in  which  the  vocal 
cords  after  phonation  scarcely  separate  at  all,  or  only  as  far 
as  the  cadaveric  position.  The  false  movements  are  most 
pronounced  in  moments  of  psychical  excitement,  or  Avhen 
an  attempt  is  made  to  breathe  properly.  In  paralysis 
of  the  abductors  the  false  movements  may  be  regarded  as 
deviations  of  the  innervation  from  the  proper  paths, 
which  are  closed,  into  improper  channels,  while  sponta- 
neous resj^iratory  spasm  may  be  explained  on  the  ground 
that  the  correct  anatomical  innervation  is  disturbed  by 
the  intervention  of  consciousness  (attention).  This  is  a 
matter  of  e very-day  occurrence  in  other  parts  of  the 
body  whenever  coordinated  movements,  which  are  usually 
performed  semi-consciously,  are  forcibly  brought  under 
the  sway  of  conscious  will-power.  Thus  a  well-drilled 
recruit  may  suddenly  turn  to  the  right,  instead  of  to  the 


96  PATHOLOGY  AND   TREATMENT. 

left,  when  a  new  inspection  takes  place,  and  the  stutterer 
stutters  most  when  he  is  trying  hardest  to  avoid  stutter- 
ing. 

Another  form  is  phonic  spasm  of  the  vocal  cords,  in 
which  the  cords,  instead  of  being  simply  approximated  in 
phonation  so  as  still  to  allow  the  passage  of  some  air,  are 
convulsively  pressed  together,  so  that  not  a  sound  can 
pass.  This  overadion  is  probably  susceptible  of  the  same 
explanation  as  perverse  innervation.  When  this  condi- 
tion has  persisted  for  some  time,  it  is  no  doubt  aggravated 
subjectively  by  the  patient's  conviction  that  he  could  not 
do  otherwise  if  he  tried. 

As  these  two  forms  of  parakinesis  are  of  a  purely 
psychical  character  and  probably  occur  only  in  "  nervous'' 
patients,  the  treatment  must  be  purely  psychical :  revive 
the  patient's  fallen  self-confidence,  raise  his  powers  of 
resistance,  and  divert  his  attention  from  his  ailment,  espe- 
cially from  its  symptoms. 

Sometimes  we  meet  with  such  intention-disturbances 
and  irregular  phonatory  movements,  manifesting  them- 
selves in  tremulousness  of  the  voice  in  professional  men, 
as  the  result  of  over-exertion  of  the  voice — i.  e.,  fatigue- 
symptoms.  The  term  mogiphony  has  been  used.  It  is 
characteristic  that  they  manifest  themselves  only  during 
the  acts  which  produced  them  in  the  first  place — preach- 
ing, reading  aloud,  singing,  etc.  They  are,  therefore, 
true  occupation-neuroses,  and  their  cause  must  be  sought 
in  the  difficulty  experienced  in  bringing  the  tired  muscles 
and  nerves  into  action. 


V.    DISTURBANCES   OF   SENSIBILITY. 

They  take  the  form  of  increased,  diminished,  or  absent 
sensibility  of  the  larynx. 

Hyperesthesia  is  very  hard  to  define,  as  the  reflex 


DISTURBANCES  OF  SENSIBILITY.  97 

sensibility  of  the  larynx  is  normally  very  great.  Reflex 
sensibility  is  much  more  marked  than  normal  sensation. 
Hyperesthesia  of  the  superior  laryngeal  nerve,  which  can 
sometimes  be  determined  by  palpating  the  upper  lateral 
border  of  the  thyroid  at  its  centre,  belongs  under  this 
head.  It  is  important  to  become  familiar  with  it,  so  as  to 
be  able  to  distinguish  it  from  sensitiveness  of  the  crico- 
arytenoid articulation,  which  lies  more  posteriorly. 

Organic  anesthesia  and  hyperesthesia  are  met  with  in 
total  paralysis  of  the  superior  laryngeal  nerve  (see  p.  94), 
or  in  partial  paralysis  aflPecting  only  the  sensory  fibers 
(after  diphtheria,  etc.).  Functional  anesthesia,  so  far  as 
our  observations  have  gone,  occurs  only  as  a  psychical 
disturbance  (hysteria).  Even  the  healthy  larynx  is  some- 
times very  callous  to  irritation  (with  the  sound),  without 
the  conditions,  indicating  hyphesthesia. 

Paresthesiae  of  the  larynx  cannot  very  well  be  dis- 
sociated from  paresthesiae  of  other  organs  in  the  throat ; 
they  consist  simply  of  abnormal  sensations  without  any 
organic  foundation  or  definite  localization.  They  are 
identical  with  general  paresthesiae  in  the  region  of  the 
throat  and  esophagus,  and  are  produced  by  the  same 
cause — the  attention  being  unduly  directed  to  the  organ 
by  unusual .  conditions  (general  excitement,  pregnancy, 
climacteric,  menstruation,  dread  of  impending  disease). 

Suggestion-therapy  offers  the  greatest  promise  of  suc- 
cess, unless  the  subjective  resistance  is  too  great  or  the 
psychical  cause  cannot  be  determined. 


V«.  COMPLICATED   (FUNCTIONAL)  MOTOR  AND  SEN- 
SORY DISTURBANCES. 

These  forms  must  be  discussed  separately,  if  only  on 
account  of  their  peculiar  etiology,  since  they  are  nothing 
but  local  manifestations  of  hysteria.  Every  variety  of 
muscular  or  nervous  paralysis  or  hyperkinesis  may  be 
functionally  simulated  by  reason  of  the  psychical  excite- 
ment. The  hysterical  symptoms  do  not  in  any  sense 
t 


98  PATHOLOGY  AND   TREATMENT. 

depend  upon  paralysis,  but  are  due  to  defective  function 
from  want  of  volitional  impulse ;  they  are  not  true 
spasms,  but  simply  the  expression  of  perverted  or  exces- 
sive, semi-conscious  volitional  impulses.  As  in  other 
parts  of  the  body,  so  in  the  larynx  the  hysterical  phenom- 
ena are  the  external  manifestations  of  imperfect  psychical 
processes,  the  bodily  recollections  of  unconscious  experi- 
ences. 

The  phenomena  are  of  the  most  varied  description ; 
they  range  from  loss  of  function  of  single  muscles  or 
areas  of  sensibility  to  total  loss  of  movement  and  sensa- 
tion ;  from  the  insignificant  "  globus  "  paresthesia  to  grave 
laryngeal  crises  ending  in  vertigo  and  unconsciousness, 
the  so-called  laryngeal  vertigo. 

The  surest  sign  of  movements  and  paralyses  being  in- 
dependent of  the  will  or  of  reflexes  is  the  disappearance 
of  the  symptoms  when  the  (morbid)  will  is  eliminated. 
Patients  with  complete  aphonia  (from  inability  to  adduct 
the  vocal  cords)  have  a  loud  cough  (Fig.  16),  and  spasms 
of  the  adductors,  or  paralyses  of  the  abductors  with  in- 
tense dyspnea,  disappear  in  narcosis.  The  phenomena 
are  so  very  variable  that  we  must  not  pronounce  certain 
conditions,  as,  for  instance,  that  of  isolated  anesthesia  of 
the  larynx,  hysterical,  even  if  no  organic  foundation  can 
be  demonstrated. 

The  latter  may  at  first  be  entirely  latent,  and  only 
manifest  itself  later  in  the  disease ;  or  it  may  be  actually 
absent,  as  in  functional  neuroses,  without  proving  that 
the  psychical  phenomena  are  produced  by  that  peculiar 
perversion  of  the  will-power  found  only  in  hysteria. 

The  fundamental  difference  between  purely  functional 
and  hysterical  disturbances  is  that  the  former  are  always 
intentional,  while  the  latter  a])parently  appear  and  disap- 
pear spontaneously.  This  variability  or  constancy  of  the 
phenomena,  which  must  appear  inexplicable  and  "capri- 
cious" to  the  observer,  depends  on  certain  latent  psychical 
processes  in  the  mind  of  the  patient  which  interrupt  or 
sustain  them. 


DISTURBANCES  OF  SENSIBILITY.  99 

The  hysterical  akineses  may  be  momentarily  or  per- 
manently interrupted  by  the  sudden  assertion  of  the  will- 
power ;  sometimes  the  motile  disturbance  has  ceased 
to  be  caused  by  psychical  conditions,  and  simply  persists 
from  force  of  habit  by  vis  inertke ;  such  cases  are  the 
most  grateful  and  j^romise  a  speedy  cure.  But  where  the 
psychical  chain  is  still  unbroken  every  eifort  fails ;  we 
may,  for  instance,  restore  the  voice  to-day  by  some  means 
or  other,  only  to  find  it  absent  again  to-morrow.  The 
treatment  must,  therefore,  concern  itself  primarily  with 
the  discovery  and  removal  of  the  latent  psychical  process. 
As  long  as  that  continues  all  remedies  will  fail.  A  great 
many  have  been  recommended  :  pressure  on  the  ovaries, 
shaking  the  larynx  during  attempted  phonation,  elec- 
tricity. 

The  patients  themselves  are  usually  not  cognizant  of 
the  psychical  cause,  and  the  best  way  to  find  it  out  is  to 
inquire  into  the  events,  both  physical  and  psychical,  which 
accompanied  the  first  appearance  of  the  symptom. 

If  the  psychical  chain  has  been  broken,  either  through 
the  efix»rts  of  the  physician  or  by  accidental,  unknown 
events,  our  professional  assistance  may  still  be  required 
to  restore  the  will-power  or  power  of  coordination  lost 
throuo^h  disuse. 

This  is  best  accomplished  by  gradually  converting  in- 
voluntary into  voluntary  movements  :  have  the  patient 
cough  and  sustain  the  sound  he  makes  in  the  act ;  once 
the  larynx  has  become  accustomed  to  the  unwonted  action, 
improvement  is  rapid.  Occasionally  the  patient  has  to  be 
taught  to  speak  all  over  again.  If  the  psychical  cause  is 
deeply  hidden  and  cannot  be  exterminated,  we  can  readily 
understand  that  the  case  will  be  hopeless.  Symptomatic 
treatment  is  required  only  when  the  symptoms  threaten 
health  and  life :  crises  and  convulsions.  The  former 
must  be  treated  by  anesthesia  during  the  attack  and  by 
general  tonics  ;  the  latter  may  call  for  tracheotomy. 


100  PATHOLOGY  AND   TREATMENT. 

VI.  DISTURBANCES   OF  THE   CIRCULATION. 

They  occur  in  tlie  larynx  as  accompaniments  or  sequelae 
of  disease  in  other  situations,  or  as  idiopathic  affections. 

Among  the  former  we  have  edema  from  stasis,  Avhich 
occurs  with  chronic  or  acute  nephritis,  cirrhosis  of  the 
liver,  or  cardiac  insufficiency;  sometimes,  too,  in  conse- 
quence of  jiressure  on  a  vein  by  an  exudate  or  a  tumor, 
in  which  case  the  edema  is  local.  The  nephritic  edema 
may  precede  all  the  other  symptoms,  and  thus  determine 
the  diagnosis  comj)aratively  early  in  the  disease. 

Edema  due  to  vasomotor  disturbances,  angioneurotic 
edema,  has  been  observed  to  occur  spontaneously  in  con- 
nection with  similar  cutaneous  edema  and  to  disappear 
again  as  rapidly. 

Sometimes  a  similar  form  of  toxic  edema  aj^pears  after 
the  exhibition  of  potassium  iodid.  We  do  not  know  why 
this,  as  well  as  the  apparently  ])urely  nervous  form, 
occurs  only  in  certain  individuals,  nor  to  what  the  edema 
is  due. 

The  treatment  in  all  these  forms  is  primarily  concerned 
with  the  removal  of  life-threatening  symptoms,  if  neces- 
sary, by  tracheotomy.  In  some  cases  cathartic  remedies 
and  cold  applications  or  scarification  may  suffice. 


VII.  SOLUTIONS   OF   CONTINUITY 

may  be  produced  by  insignificant  causes  if  the  vulnerabil- 
ity is  abnormal,  or  by  ordinary  traumatism. 

The  former  occur  in  hemophilia,  general  arteriosclero- 
sis, syphilis,  tumors,  tedious  catarrhs  of  long  duration, 
and  in  secondary  macerations  (see  p.  60).  Com ]ia rati vely 
slight  injuries,  such  as  forcing  the  voice,  violent  cough, 
painting  the  larynx,  may  suffice  in  such  cases  to  bring  on 
hemorrhages  in  or  on  the  surface  of  the  tissues,  or  even 


SOLUTIONS  OF  CONTINUITY.  101 

fissures  and  transverse  severing  of  the  vocal  cords.  In 
the  two  first-named  diatheses  small  operations,  which 
ordinarily  are  attended  Avith  only  very  little  bleeding, 
may  endanger  life  by  the  hemorrhages  they  occasion.  If 
a  severe  hemorrhage  in  the  larynx  cannot  be  controlled 
by  making  the  patient  swallow  ice,  by  the  application  of 
cocain,  a  strong  alum  solution,  or  the  galvanocautery, 
tracheotomy  must  be  performed  immediately  without  anes- 
thesia— as  blood  is  aspirated  during  anesthesia  even  when 
the  head  hangs  down — and  the  larynx  packed  with  tam- 
pons from  above  or  from  below. 

Traumatic  lesions  of  the  larynx  result  from  shot- 
wounds,  cuts,  and  stab-w^ounds,  or  from  contusions. 
According  to  situation  and  intensity,  there  is  more  or 
less  division  or  fracture  of  the  cartilages,  or  hematomata 
appear  in  the  mucous  membrane,  or  even  free  hemor- 
rhages. The  immediate  consequence  (where  asphyxia 
does  not  occur  at  once)  is  fatal  dislocation  of  the  respira- 
tory path,  and  this  usually  demands  tracheotomy  and 
eventually  intubation.  Cut-wounds  may  heal  entirely 
after  removal  of  the  sutures,  but  usually  they  leave  a 
membranous  or  cicatricial  stenosis  which  must  be  removed 
by  excision  or  by  stretching,  either  from  within  or  after 
opening  the  larynx. 

It  is  always  well,  in  doubtful  cases,  to  perform  this  last 
operation  at  once,  in  order  to  clear  up  the  diagnosis  and 
to  remove  any  possible  obstructions  (luxated  fragments  of 
cartilage,  etc.).  It  is  just  such  injuries  as  these  that  give 
rise  to  the  curious  deformities  which  we  meet  with  in  the 
larynx. 

Thermal  or  chemical  injuries  of  the  larynx  result  from 
the  aspiration  of  hot  or  caustic  gases,  or  from  accidental 
entrance  of  caustic  liquids  into  the  larynx  in  deglutition. 
The  consequence  in  light  cases  is  violent  catarrh  with  ero- 
sions ;  in  more  severe  cases,  diphtheritic  membrane-for- 
mation, edema,  ulcers,  and,  finally,  intense  cicatrization. 
The  treatment  is  purely  symptomatic  :  ice  internally  and 
externally ;  if  necessary,  tracheotomy,  not  intubation. 


102  PATHOLOGY  AND   TREATMENT. 

VIII.  FOREIGN   BODIES 

frequently  find  their  way  into  the  interior  of  the  larynx, 
especially  in  children.  Convulsive  cough,  spasm  of  the 
vocal  cords,  injuries,  or  direct  mechanical  suffocation, 
later  irritative  inflammations  and  decubital  ulcers,  are  the 
consequences. 

Every  means  must  be  tried  to  remove  the  obstruction 
on  account  of  the  danger  of  asphyxiation  or,  at  least, 
aspiration  into  the  bronchi  and  consequent  inspiration- 
pneumonia.  Small,  movable  bodies  are  easily  coughed  up 
after  tracheotomy,  especially  if  no  cannula  is  introduced 
and  the  edges  of  the  tracheal  wound  are  sewed  to  the 
edges  of  the  skin.  In  other  cases  the  foreign  body  must 
be  removed  from  within  or  after  performing  the  opera- 
tion of  laryngofissure. 


IX.  MALFORMATIONS. 

The  development  of  male  larynges  may  be  retarded  so 
that  they  come  to  resemble  the  female  larynx  in  size  and 
shape ;  it  occurs  especially  as  a  part  of  a  general  feminism. 
Imperfect  union  of  the  two  halves,  as  in  cleft  palate,  with 
which  it  is  usually  associated,  has  been  observed  in  the 
form  of  longitudinal  fission  of  the  epiglottis.  Congenital 
absence  of  the  epiglottis  has  also  been  described. 

A  kind  of  atavistic  malformation  is  seen  in  the  lateral 
expansion  of  the  ventricles  of  Morgagni,  analogous  to 
the  resonating-pouches  of  anthropoid  apes,  known  as 
laryngocele.  In  well-developed  examples  the  pouch 
pushes  the  hyothyroid  membrane  before  it  and  becomes 
visible  on  the  outside  of  the  neck,  especially  during 
attacks  of  coughing.  Smaller  extensions  are  more  com- 
mon. 

Congenital  mcmhranes  have  been  observed  occasionally 
within  the  ventricle,  dividing  it  into  two  compartments. 


MALFORMA  TIONS.  1 03 

They  are  more  frequent  between  the  vocal  cords;  the 
least  developed  forms  appear  as  a  mere  broadening  of  the 
commissure. 

Ei^tensive  membrane-formations,  sometimes  of  the 
hardness  of  cartilage  and  always  beginning  at  the  com- 
missure, produce  severe  dyspnea  in  addition  to  complete 
aphonia,  and  often  demand  radical  excision,  to  be  followed 
by  a  course  of  stretching. 

Membranes  have  even  been  observed  above  the  vocal 
cords,  completely  covering  the  glottis. 

The  treatment  is  the  same. 

We  have  already  referred  to  the  occurrence  of  dislo- 
cated tissue  from  the  thyroid  gland  on  p.  81. 


Tab.     1 


Fuf.Ji. 


FufJ. 


LUh.  Anst  /.'  Reichhold,  Afdiich^i. 


PLATE   1. 
Fig.  I 

shows  an  image  of  the  anterior  surface  of  the  epiglottis  taken 
in  the  Kilhan  posture  (head  bent  well  forward);  the  lower 
border  of  the  cricoid  is  seen  projecting  from  the  trachea,  which 
is  exposed  to  some  depth. 

Fig.  2 

is  the  picture  of  a  very  large  and  wide  female  larynx,  showing 
the  anterior  wall  of  the  trachea,  the  bifurcation,  and  parts  of 
the  main  bronchi. 


PLATE  2. 
Fig.  I. 

represents  the  shape  of  a  child's  larynx  (the  "  omega  "  shape). 
The  posterior  parts  are  sometimes  even  more  approximated,  so 
that  the  aperture  of  the  larynx  is  entirely  covered. 

Fig.  2. 

A  gentleman,  65  years  old,  has  an  enormously  enlarged  neck  from  a 
struma  (circumference,  51*  cm.). 

The  larynx  is  displaced  to  the  left  about  3  cm.  from  the  middle  line ; 
the  upper  border  of  the  cricoid  is  liigher  on  the  right,  than  on  the  left 
side.     Marked  stridor  and  cyanosis  i)oint  to  a  stenosis.     Voice  normal. 

The  epiglottis  and  the  posterior  wall  are  bent  slightly  back- 
ward on  the  right  side.  The  right  true  and  false  vocal  cords 
cannot  be  seen  at  all,  as  the  commissure  is  under  the  middle 
of  the  petiolus,  instead  of,  as  usual,  at  the  right  angle  of  the 
epiglottis. 

In  phonation  the  left  vocal  cord  is  drawn  far  over  to  the  right  and 
the  arytenoid  cartilage  is  drawn  sharply  inward.  The  peculiar  image 
is  therefore  due  to 

Oblique  Position  of  the  Larynx  from  Struma. 

Fig.  3. 

A  woman,  46  years  old,  complains  of  difficulty  in  swallowing  for  the 
past  year;  there  is  no  pain,  but  inability  to  swallow  any  large  morsel. 
There  is  nothing  abnormal  in  the  pharynx. 

Larynx. — There  is  not  much  alteration,  except  a  broad  red 
swelling  which  projects  from  the  posterior  wall. 

The  tumor  does  not  move  in  phonation ;  on  the  contrary,  the  pos- 
terior wall  is  seen  to  glide  past  it,  and  it  becomes  evident  that  the  tumor 
does  not  arise  from  the  larynx. 

Digital  palpation  reveals  that  it  is  seated  immediately  above,  but  not 
in  relation  with  the  aperture  of  the  larynx,  and  extends  sideways  as  well 
as  upward  and  downward  on  the  posterior  wall  of  the  pharynx.  The 
tumor  is  very  hard  and  the  mucous  membrane  is  stretched  very  tight. 
This  tumor  must,  therefore,  originate  in  the  vertebra?,  and  probably  has 
nothing  to  do  witli  the  dysphagia,  as  the  finger  easily  glides  past  it  into 
the  sinus  pyriformis.     It  is,  in  fact,  an  old 

Lordosis  of  the  Cervical  Vertebrae. 

A  sound  was  introduced,  and  the  dysphagia  explained  by  the  finding 
of  a  solid  obstacle  in  the  esophagus,  in  the  neighborhood  of  the  bifurca- 
tion. 


Tab.     2. 


ru,.i. 


Fiff.S 


w 


FiffJ. 


I.ilh.  Ansl  F.  Reichhold.  Miinchen. 


Tab.     3 


Fifil 


Fifj. 


,v»  9 


/Mh.  Arusl  E  Heu'hhoUi,  Miinchen. 


PLATE   8. 
Fig.    I 

represents  a  normal  larynx  of  someAvhat  unusual  appearance, 
because  in  respiration  the  true  vocal  cords  recede  more  than 
is  normal  under  the  ventricular  bands,  the  latter  making  a 
wide  curve  inward  and  backward. 


Fig.  3. 

A  man,  27  years  old,  has  a  deep,  rough  voice  and  betrays  great  exer- 
tion during  phonation.  We  may  mention  briefly  that  anamnesis  and 
examination  reveal  recently  developed  tuberculosis  of  the  lungs  and 
larynx  (slight  infiltration  of  the  posterior  wall  and  pale,  relaxed  vocal 
cords). 

In  phonation  the  true  vocal  cords  suddenly  disappear  under 
the  ventricular  bands,  which  are  drawn  unusually  far  toward  the 
middle  line ;  the  edges  of  the  latter  are  slightly  red  and  form 
another  superior  glottis,  responding  to  the  current  of  air  by 
perceptible,  coarse  vibrations.      It  is  the  picture  of  so-called 

Vicarious  Phonation  of  False  Vocal  Cords. 


Fig.  3. 

A  girl,  17  years  old,  is  examined  for  nose-bleed  and  headache,  which 
are  found  to  be  caused  by  deep  tertiary  syphilitic  ulcers  in  the  interior 
of  the  nose.  Deficiencies  in  the  soft  palate  and  uvula  show  that  similar 
processes  have  taken  place  before.  The  voice  has  a  good  sound,  but  its 
quality,  owing  to  these  deficiencies,  is  nasal. 

Laryngoscopy  at  once  shows  an  extensive  destruction  involv- 
ing more  than  half  the  epiglottis.  Of  the  latter  only  the  an- 
terior, basal  half  remains.  There  are  several  notches  on  the 
left  side  and  a  deep  incision  in  the  middle.  What  remains  is 
pale  red ;  the  edge  is  slightly  wavy,  and.  the  surface  covered 
with  fairly  uniform,  flat  nodules. 

The  other  parts  are  pale  but  otherwise  intact.  From  the  findings  in 
other  parts  of  the  body  it  is  evident  that  these  alterations  are  the 

Remains  of  Syphilitic  Ulcers. 


PLATE  4. 

Fig.    I. 

A  gentleman,  54  years  old,  with  all  tlie  signs  of  a  viveur,  has  been 
hoarse  for  the  past  six  weeks.     Home  remedies  had  no  elfect. 
Nothing  abnormal  in  mouth,  nose,  or  fauces. 

Laryngoscopy  shows  the  right  edge  of  the  epiglottis  to  be 
hypertrophied  and  slightly  red.  The  hypertrophy  consists  of 
several  smooth,  round  nodules,  about  the  size  of  a  barley-corn. 
The  right  true  and  false  vocal  cords  are  slightly  red  and  hyper- 
trophied. 

No  swelling  of  glands  nor  abnormalities  in  the  skin  or  skeleton  could 
be  made  out;  lungs  and  heart  normal.  Patient  denies  any  infection 
but  gonorrhea.  The  nodules  on  the  epiglottis  can  hardly  be  regarded  as 
swollen  lymph-follicles,  though  they  exist  in  this  region  ;  the  fact  that 
they  are  limited  to  one  side,  and  the  unilateral  inflammation  of  deeper- 
lying  parts,  point  either  to  an  infectious  or  to  a  malignant  process.  The 
latter  is  excluded  by  the  occurrence  of  two  essentially  different  eruptions 
in  different  localities.  There  remain  tuberculosis  and  syphilis.  The  for- 
mer is  improbable  in  view  of  the  man's  general  health,  whicli  is  robust, 
and  also  on  account  of  the  short  duration  and  the  marked  inflammatory 
symptoms.  Everything  is  in  favor  of  syphilis ;  his  denial  goes  for 
nothing.  We  have  to  deal  with  the  initial  stage  of  a  tertiary  process 
with 

Fresh  Gummata  on  tlie  Epiglottis  and  Syphilitic  Infiltration  of  the 
Right  True  Vocal  Cord. 


Fig.  2. 

A  heavy  drinker,  32  j'ears  old,  has  been  suffering  from  hoarseness 
and  occasional  irritating  cough  for  six  months.  No  expectoration.  No 
family  history  could  be  obtained.  The  voice  is  entirely  without  sound. 
The  fauces  present  nothing  unusual ;  the  mucous  membrane  is  thick- 
ened and  of  a  dull  red,  as  is  frequently  the  case  with  drinkers. 

Larynx. — The  under  surface  of  the  epiglottis  is  somewhat 
broad  nnd  covered  with  numerous  flat,  pale  red  nodules  closely 
packed  together.  Similar  nodules  are  seen  along  both  true 
and  false  vocal  cords  and  on  the  anterior  surface  of  the  aryte- 
noid cartilages ;  in  the  latter  situation  they  take  the  form  of 
actual  tumors. 

Movement  of  both  cords  is  only  sliglitly  impaired.  Although  ex- 
amination of  the  hmgs  gives  no  very  abnormal  result,  the  appearance 
of  the  chronic,  nodular,  and  diffuse  infiltration  in  various  situations  per- 
mits the  diagnosis  of 

Tuberculosis  resembling  Lupus. 


Tab      4. 


iifjl 


Fig. 


^ 


FigJ. 


Lith.  Anst  F.  Reichkold,  Miinchen. 


Tab.     5. 


yi(f.i 


tUf.}i. 


Fiif.y. 


l.Utu  Anst  F.  RjtichJtwld,  Mundven . 


PLATE    5. 

Fig.  I. 

A  man,  45  years  old,  has  been  suffering  for  six  months  with  increas- 
ing lioarseness  and,  lately,  dysjjnea  on  going  up-stairs,  etc.  He  himself 
attributes  his  trouble  to  a  cliancre-infection  received  t'onr  years  ago. 

The  voice  is  raucous  and  almost  without  sound  ;  the  general  appear- 
ance is  robust  and  v^ell  nourished ;  lungs  are  sound,  only  the  inguinal 
glands  are  slightly  swollen.  In  the  nose  there  is  nothing  abnormal,  but 
on  the  posterior  wall  of  the  pharynx  are  seen  welt-like  scars,  and  the 
larynx  i)resents  extensive  changes. 

Tlie  epiglottis  as  a  whole  is  hypertrox^hied ;  the  edges,  es- 
pecially the  anterior,  uneven  and  in  parts  covered  with  large 
nodules. 

The  left  half  presents  a  deep  fissure,  so  that  a  superficial 
fragment  can  be  isolated  from,  the  deeper-lying  remainder  of 
the  substance.  The  posterior  portion  is  further  defaced  by  a 
discolored,  dirty-yellow  ulcer. 

The  left  true  and  false  vocal  cords  are  replaced  by  a  thick, 
wavy  strip  of  dense,  dark-red  tissue ;  the  right  ventricular  band 
is  of  a  brighter  red,  and  swollen  in  front  and  behind  to  such  a 
degree  that  it  completely  covers  the  true  cord,  which  is  also 
hypertrophied  and  yellowish-red  in  color.  A  thick  red  projec- 
tion rises  abruptly  from  the  posterior  wall  on  the  right  side, 
and  a  lower  ragged  excrescence  on  the  left  side,  as  well  as  the 
investment  of  the  arytenoid  cartilage,  is  covered  by  a  radiat- 
ing white  scar. 

Without  a  histological  examination  of  extirpated  tissue,  or  the  obser- 
vation of  the  subsequent  course  of  the  disease,  it  is  impossible  to  decide 
between 

Syphilis  and  Tuberculosis. 

(Later  the  disease  turns  out  to  l)e  purely  syphilitic  in  character.    The 
hyperplasia  on  the  posterior  wall  is  due  to  a  latent  perichondritis.) 

Fig.  2. 

A  man,  32  years  old,  was  treated  a  year  ago  for  tertiary  syphilis  of 
the  nose.  Now  he  comy)lains  that  liis"  throat  has  been  troubhng  him 
for  several  months  and  he  has  gradually  almost  lost  his  voice. 

Nothing  unusual  in  the  fauces. 

In  the  place  of  the  epiglottis  we  see  a  shapeless  mass  of 
tissue :  a  broad,  irregular  plate,  the  free  edge  very  much 
thickened,  overhangs  the  left  side  of  the  epiglottis.  The  upper 
surface  presents  two  circumscribed  inflammatory  areas  and,  in 
the  center  of  each,  an  ulcer  as  large  as  a  pea  with  well-marked 


edges  and  dirty-yellow  floor;  the  one  lying  near  the  middle 
line  has  taken  part  in  the  destruction  of  the  free  edge  of  the 
overhanging  plate.  A  deep  ragged  cleft  separates  this  entire 
mass  from  a  smaller- fragment  on  the  left,  which  evidently 
represents  the  remains  of  the  left  half  of  the  epiglottis. 

Owing  to  the  swollen  ventricular  band  the  vocal  cord  on  the 
right  side  apjDears  to  be  narrowed,  injected,  and  rough  (at  the 
free  edge) ;  on  the  left  side  it  is  entirely  hidden  by  the  ventric- 
ular band,  which  is  very  red  and  swollen.  All  that  apparently 
remains  of  the  true  cord  is  a  spur  projecting  from  under  a 
similar  ulcer  to  the  one  just  described,  and  perhaps  the  re- 
mains of  the  processus  vocalis.  Both  aryepiglottidean  liga- 
ments are  likewise  red  and  swollen;  the  right  one  has  a  yel- 
lowish hue.  From  under  the  latter  a  blunt  red  pyramid  about 
half  as  large  as  a  pea  is  seen  to  project  into  the  lumen. 

The  appearance  of  these  sharply  eircumscribed  ulcers,  even  without 
the  anamnesia,  gives  the  diagnosis  of 

Tertiary  Infiltrative  and  Destructive  Syphilis. 


Fig.  3. 

A  man,  40  years  old,  was  infected  with  syphilis  seventeen  years  ago ; 
since  then  he  has  had  manifestations  of  the  disease  in  the  skin  of  the 
back,  on  the  shins,  in  the  nose,  and  finally,  six  years  ago,  in  the  larynx. 
Although  the  laryngeal  affection  was  relieved  by  general  treatment,  as 
far  as  the  pain  was  concerned,  he  now  begins  to  suffer  more  and  more 
from  dyspnea. 

The  entire  larynx  is  deformed.  The  epiglottis  consists  of 
a  swollen  band,  thicker  on  the  right  side  than  on  the  left  and 
approaching  the  turban-shape.  The  surface  is  smooth  and  red. 
The  ventricular  bands  are  replaced  by  thick  pale-red  shreds  of 
tissue ;  only  one  little  corner  of  the  vocal  cord  is  seen  on  the 
left  side,  the  right  does  not  appear  at  all  (not  even  in  phona- 
tion).  The  entire  posterior  wall  is  converted  into  a  massive 
horseshoe,  on  the  anterior  surfjxce  of  which  are  two  broad 
elevations,  the  left  one  marked  with  a  notch.  A  number  of 
smaller  convolutions,  resembling  a  chain  of  hills,  spring  from 
the  anterior  surface  of  the  cricoid  cartilage.  The  mucous 
membrane  appears  to  be  intact  everywhere. 

The  voice  is  feeble  and  of  a  deep,  grunting  quality  (false  vocal  cord 
phonation). 

The  whole  picture  may  be  explained  as  the  remains  of  destructive 
gummata,  although  the  hypertrophy  of  the  posterior  wall  is  very  re- 
markable. 

The  proliferation  of  the  tumors  must  be  restricted  in  order  to  relieve 
the  dysj)nea :  microscopic  examination  of  tlie  extirpated  portions  reveals 
onlv  harmless  connective  tissue  and  epithelial  proliferation.  (See  PI. 
41,  Fig.  1.) 


The  tumors  recur,  however,  and  pain  is  frequently  felt  in  speaking 
and  in  swallowing. 

This  state  of  afiairs  continues  several  years.  The  long  duration  with- 
out material  changes  in  the  type,  more,  even,  than  the  histological 
picture,  excludes  malignant  growths.  Nor  have  we  to  deal  with  syphil- 
itic manifestations,  as  there  is  no  reaction  to  mercury  or  potassium 
iodid,  and  no  signs  are  found  elsewhere  on  the  body.  We  are  there- 
fore inclined  to  regard  the  recurring  proliferations  as  the  expression  of 
the  reaction  to  a  still-existing  inflammatory  irritation,  to  which  we  may 
also  refer  the  hypertrophy  of  the  posterior  wall. 

We  assume  then,  with  some  sliow  of  probability,  a 

Chronic  Secondary  (Post-syphilitic)  Perichondritis, 

caused  by  necroses  which  have  not  yet  been  eliminated. 


Tab.      7 


IUf.2 


Fuf.M. 


Liih.  A  fist  F.  EfiichhvUi.  Munch 


PLATE   7. 

Fig.  I. 

A  single  woman,  31  years  old,  has  been  ill  two  days  with  fever,  sore- 
throat,  and  hoarseness.  No  dyspnea.  The  soft  palate  and  both  tonsils 
are  slightly  red ;  the  left  tonsil  slightly  enlarged  and  flecked  with  pus. 
The  X->osterior  pillar  on  the  right  side  is  also  slightly  enlarged. 

Submaxillary  glands  on  the  left  side  palpable  and  painful. 

Laryngoscopy. — The  entire  left  half  of  the  epiglottis,  as 
well  as  the  left  glosso-epigiottidean  ligament,  is  converted  into 
tense,  shiny  tumors  of  a  yellowish-gray  color.  The  left  ary- 
epiglotticlean  ligament  is  slightly  thickened.  The  vocal  cords, 
on  the  other  hand,  are  w'hite. 

Their  mobility  ls,  however,  much  impaired:  both  approximation  and 
tension  are  incomplete  in  phonation. 
The  picture  is  interpreted  as  that  of 

Acute  Infectious  Edema 

originating  in  tonsillar  infection. 

Fig,  2 

is  the  postmortem  picture  of  the  larynx  of  a  very  fat  man  who 
died  suddenly  of  asphyxia.  The  entire  epiglottis  and  the 
mucous  memhrane  covering  the  right  half  of  the  cricoid  car- 
tilage are  puffed  out  and  very  red  and  swollen.  In  this  case  a 
more  intense  process  was  at  w^ork  than  in  the  last  illustration — 
an 

Acute  Infectious  Phlegmon, 

probably  erysipelatous  in  character. 


PLATE   8. 

Fig.  I. 

A  man  with  a  weak,  sighing,  high-pitched  voice  comes  with  a  history 
of  acute  catarrh  which  began  ten  days  ago. 

In  this  case  also  the  arytenoidean  region  is  especially  in- 
flamed, although  the  rest  of  the  laryngeal  mucous  membrane 
is  likewise  somewhat  injected.  During  phonation  the  posterior 
part  of  the  glottis  remains  open  in  the  form  of  a  triangle,  while 
the  anterior  part  is  spasmodically  closed. 

It  is  therefore  an 

Inflammatory  Paralysis  of  the  Transverse  Arytenoid  Muscle. 


Fig.  2. 

A  man,  38  years  old,  caught  cold  at  a  ball  two  days  ago  and  has  been 
hoarse  since.  His  throat  is  dry  and  he  has  a  "  scratchy  "  feeling  when 
he  swallows. 

The  uvula  is  sHghtly  rod  ;  otherwise  the  fauces  are  normal. 

The  redness  is  limited  to  the  internal  edges  of  the  true  vocal 
cords,  and  is  especially  marked  between  the  two  arytenoid  car- 
tilages. There  is  almost  no  sound  in  phonation,  the  arytenoid 
cartilages  not  approximating  perfectly;  the  glottis  forms  a 
double  ellipse,  the  point  of  tangency  being  at  the  apices  of  the 
two  vocal  processes. 

Diagnosis : 

Inflammatory  Paralysis  of  the  Internal  Thyro-arytenoid  and  of  the 
Transverse  Arytenoid  Muscles. 


Tab.     8. 


Fiff.1, 


Fiff.^. 


lith .  Anst  /•:  ReichhMd.  Mimchen . 


Fiff.l. 


Fiq. 


Tail 


/,/;,     )/,v/    f-'  l/i>irhluili}    Xfii/it.' 


PLATE    9. 

Fig.  I. 

A  girl,  25  j'-ears  old,  with  a  history  similar  to  that  of  Fig.  2  in  PI.  8, 
presents  a  somewhat  different  picture. 

The  epiglottis  is  strongly  injected  and  the  mucous  membrane 
over  the  arytenoid  cartilages  also  appears  red,  especially  the 
vocal  cords.  In  phonation  they  exhibit  a  rather  wide  eUiptical 
cleft ;  the  voice  is  rough  and  very  feeble. 

We  have  to  deal  with  a  case  of 

Acute  Laryngeal  Catarrh  with  Inflammatory  Paresis  of  the  Internal 
Thyro-arytenoid  Muscles. 

Fig.  2. 

Marked  vocal  disturbance  is  the  most  conspicuous  symptom  in  a  man 
suffering  from  incipient  tuberculous  infiltration  of  both  apices. 

The  epiglottis  is  unusually  pale ;  the  outline  of  the  free  margin 
is  "interrupted  by  two  small,  nodular  eminences  on  the  left  side. 

The  rima  giottidis  gapes  during  phonation,  because  the  pars 
phonatoria  of  the  right  vocal  cord  presents  an  elliptical  con- 
cavity of  the  free  edge.  The  left  cord  is  properly  stretched,  but 
its  middle  third  shows  an  area  of  redness  limited  externally  by 
a  convex  boundary. 

This  "  unilateral  catari'h  "  without  any  other  symptoms  is  suspicious. 
The  want  of  tone  in  the  right  vocal  cord  is  probably  not  due  to  muscular 
weakness  alone,  such  as  occurs  in  the  early  stages  of  tuberculosis,  but, 
from  the  fact  that  it  is  unilateral,  also  to  tuberculous  infiltration  of  the 
thyro-arytenoid  muscle.  Besides,  the  nature  of  the  nodules  on  the  epi- 
glottis is  unmistakable.     We  must,  therefore,  diagnose 

Multiple  Tuberculous  Infiltrations  in  the  Early  Stage. 


PLATE   10. 

Fig.  I. 

A  gentleman,  65  years  old,  is  hampered  in  the  discharge  of  his  pro- 
fessional duties  by  an  intense  hoarseness  which  has  been  recurring  at 
varying  intervals  for  years.  The  present  attack  began  six  weeks  ago. 
He'also  complains  of  violent  "stomach-trouble,"  which  manifests  itself 
in  morning  retching  and  vomiting,  although  the  appetite  is  entirely 
undisturbed.  He  has  been  very  temperate  in  the  use  of  alcohol  and 
tobacco  for  years. 

Examination  of  the  chest  reveals  only  slight  emphysema  with  traces 
of  bronchial  catarrh. 

The  fauces  are  of  a  dusky  red ;  the  mucous  membrane  everywhere 
presents  an  uneven  surface  traversed  by  dilated  veins ;  even  the  base  of 
the  tongue  is  hypertrophied  and  deep  red  in  color. 

In  the  pharynx  some  tough  mucus.  Traces  of  a  similar  secretion  are 
seen  on  the  floor  of  the  nose  and  on  the  septum  in  front. 

The  anterior  exti-emities  of  the  middle  turbinated  bones  are  enlarged. 

The  larynx,  as  a  whole,  is  of  a  dark-red  color.  A  smooth 
fold  of  mucous  membrane  projects  from  the  posterior  wall,  and 
similar  ones  from  the  lower  borders  of  the  vocal  processes.  On 
the  posterior  portions  of  the  vocal  cords  are  seen  some  irregular 
dark-red  spots,  flat  and  adherent,  not  movable  in  coughing. 

This  is  a  general  picture  of  secondary  chronic  laryngitis,  somewhat 
specialized  in  this  case  by 

Inflammatory  Hyperplasise  and  Hemorrliages. 

Fig.  2. 

A  girl,  17  years  old,  has  been  suffering  for  six  months  with  hoarse- 
ness and  loss  of  appetite.  Every  morning  she  hawks  up  and  discharges 
from  the  nose  a  great  fiuantity  of  tough,  yellow  mucus.  The  act  is 
attended  with  much  difficulty  and  often  followed  by  complete  aphonia. 
Tlie  father  has  tuberculosis  of  the  larynx.  The  voice  is  very  rough  and 
croaking,  and  often  changes  suddenly  to  a  different  rt^cister.  The 
general  condition  is  reduced  ("flaccid");  complexion  a  dirty  yellow, 
although  the  mucous  membrane  of  the  mouth  is  not  much  discolored. 
Lungs  and  heart  normal.     Urine  free  from  albumin. 

The  posterior  wall  of  the  pharynx  and  the  arch  of  the  palate  are 
covered  with  tough  masses  of  mucus;  also  the  anterior  extremities  of 
both  middle  and  turl)inatod  bones.  (Upon  closer  examination  a  puru- 
lent f(K;us  is  found  on  both  sides  of  the  septum  in  front.) 

Larynx. — General  anemia.  Both  vocal  cords  are  of  a  yellow- 
ish-gray, covered  with  spots;  the  surface  uneven  and  giving  the 
effect  of  maceration  ;  the  free  edges  are  rough,  so  that  closure 
is  incomplete  during  phonation  (Fig.  2a). 

Tbo  diatrnosis  of  secondary  maceration  of  the  true  vocal  cords  by 
pus  from  the  nose,  wliifh  was  made  from  the  objoctivc  signs,  is  confirmed 
by  the  subsequent  course,  inasmuch  as  all  tlie  phenomena  were  made  to 
disappear  by  treati-ng  the  purulent  focus  in  the  nose. 


Tab.   10. 


Tig.l. 


Fig.S 


i         \ 


\ 


Fxg.3. 


Lith.Arist  H Reichhoid .  Miincheii. 


Fiffl. 


Fiff.^. 


Tab.   11. 


l.ilft    An.sl   I.  Rpuhhniil  Xtiiiirhcn 


PLATE  11. 

Fig.  I. 

A  gentleman,  in  his  56th  year,  seeks  advice  for  hoarseness  which  began 
about  six  months  ago.  The  voice  is  deep,  toneless,  and  rough ;  some- 
times it  is  lost  entirely.  The  man  has  a  well-nourished  appearance;  is 
not  too  fat  for  his  years ;  his  face  is  somewhat  red.  There  is  a  little 
cough,  weak  and  noiseless  and  sometimes  painful.  He  complains  chiefly 
of  dryness  and  occasional  stabbing-pains  in  the  throat ;  the  patient  has 
been  a  heavy  smoker,  but  a  moderate  drinker.  Physical  examination 
reveals  some  enlargement  of  the  lung-area,  otherwise  nothing  abnormal. 

The  entire  larynx,  and  especially  the  vocal  cords,  are  very 
red.  The  latter  also  exhibit  a  yellow  discoloration  in  the  neigh- 
borhood of  the  apices  of  the  vocal  processes,  circumscribed  in 
character  and  not  affected  by  cough,  extending  over  the  upper 
surface  and  along  the  inner  margin. 

They  are,  therefore,  not  depositions  of  secretions,  but  alterations  of 
the  epithelium  itself — erosions.  As  there  are  no  grounds  for  suspecting 
any  other  cause  than  the  evident  catarrhal  condition,  they  may  be  re- 
garded as 

Catarrhal  Erosive  Ulcers 

of  decubital  origin  (from  compression  of  the  processus  vocales). 

Fig.  2. 

An  appparently  healthy  man,  62  years  of  age,  lost  his  voice  three 
weeks  ago  ;  it  had  been  growing  weaker  and  weaker  for  some  time.  He 
says  he  has  never  been  sick.  Nothing  abnormal  in  nose  and  throat. 
Aphonia. 

The  posterior  half  of  each  vocal  cord  is  apparently  narrowed, 
while  the  anterior  portion  is  thrust  forward  in  the  form  of  a 
flabby  irregular  lobule.  These  lobules  are  of  a  dull-white  color, 
while  the  remaining  visible  portions  of  the  vocal  cords  and  the 
median  borders  of  the  ventricular  bands  are  intensely  red.  The 
apparent  narrowing  of  the  vocal  cords  is  due  to  the  inflamma- 
tory swelling  of  the  ventricular  bands. 

These  alterations,  from  their  acute  onset,  permit  of  but  one  interpre- 
tation ;  they  are 

Syphilitic  Papillomata. 

Neither  the  patient's  age  nor  his  denial  should  affect  the  diagnosis. 


PLATE  12. 

Fig.  I. 

A  young  man  who  was  affected  with  syphiHs  ten  weeks  ago  com- 
plains of  pain  in  the  mouth  and  throat ;  he  took  cold  two  weeks  ago  and 
has  since  become  hoarse. 

In  the  mouth  conspicuous  condylomata  are  seen  on  the 
mucous  membranes  of  the  cheek.  The  entire  larynx  is  some- 
what injected.  Both  vocal  cords  are  red,  the  right  more  than 
the  left.  Over  the  right  vocal  process  there  is  a  whitish-yellow 
prominence  with  sharply  defined  red  base  reposing  on  the 
somewhat  swollen  background — a  true 

SypMlitic  Papilloma. 

Fig.  2. 

A  man,  30  years  old,  who  has  been  under  treatment  for  pulmonary 
tuberculosis  for  years  and  has  been  much  benefited  by  climatic  cures, 
seeks  relief  for  chronic  hoarseness. 

The  voice  is  raucous  but  loud. 

There  is  some  dulness  at  the  apices  of  both  lungs,  with  circumscribed 
bronchial  breathing  and  a  few  rales. 

The  larynx  as  a  whole  is  rather  pale.  The  posterior  wall, 
which  is  hypertrophied,  presents  on  its  anterior  surface  several 
rows  of  flat,  wavy  elevations  merging  into  one  another.  The 
left  vocal  cord  is  reduced  to  a  narrow  strip  ;  the  right,  which  is 
broader  and  has  an  uneven  edge,  presents  about  the  middle  a 
whitish  eminence  surrounded  l)y  a  narrow,  pale-red  zone  of  in- 
flammatory tissue  ;  behind  the  hitter  two  other  nodules  are 
seen,  pale  red  in  color  and  about  the  size  of  a  millet-seed.  The 
right  ventricular  band  appears  to  blend  with  these  nodules,  and 
for  the  rest  is  also  swollen  and  convohited. 

On  the  left  side  we  i)robably  have  the  remains  of  a  destructive  process ; 
cicfitrizatlon  is  now  complete,  as  is  shown  by  the  absence  of  proliferation 
or  inflammation.  On  tlie  right  side  the  i)rocess  is  evidently  still  going 
on,  while  the  hypertrophy  of  the  posterior  wall  appears  to  depend  on 
deeper-lying  alterations,  since  the  superficial  })roliferations  still  persist. 
The  entire  picture,  viewed  in  connection  with  the  anamnesis,  represents 
therefore  a 

Mixture  of  Destructive  and  Retrogressive  Tuberculous  Infiltrations. 


Tab.   12. 


Figl. 


Fuf.^ 


J? 


LUh.  Aixst  F.  Reirhhold  Miinrhen . 


Tab.   l:S. 


ri„.i. 


Fig.a. 


Fig.,i. 


LUh:  Anst  /.'  fietrAhold,  Miiiichei 


PLATE  13. 

Fig.  I. 

A  woman,  28  years  old,  has  been  sutfering  for  the  past  week  with  pain 
in  the  left  side  of  tlie  throat  radiating  toward  the  ear.  The  voice  was 
entirely  without  sound  ;  sometimes  the  patient  could  not  speak  above  a 
whisper.  Now  the  voice  is  croaking,  and  small  in  volume  almost  to 
aphonia.  The  woman  is  well  nourished  and  shows  no  signs  of  illness. 
She  says  she  has  always  been  well. 

In  the  larynx  everything  is  normal  but  the  left  vocal  cord. 
It  is  almost  twice  as  broad  as  its  fellow,  of  a  rounded  form  and 
strongly  injected.  

•Mobility  is  only  slightly  impaired. 

These  phenomena  are  apparently  purely  catarrhal  in  character,  but 
there  is  no  such  thing  as  unilateral  catarrh  ;  such  affections  always  de- 
pend upon  a  deeper  lesion,  iLsually  of  an  infectious  nature.  That  it  is 
infectious  in  this  case  is  proved  by  the  short  duration,  which,  together 
with  the  intense  inflammation,  leads  us  to  decide  in  favor  of  syphilis. 
Although  the  anamnesis  furnishes  no  positive  data,  we  nevertheless 
abide  by  this  diagnosis  and  conclude  that  we  have  to  deal  with  the  ter- 
tiary period.    It  is,  therefore,  a 

Gummatous  Infiltration  of  the  Vocal  Cord. 

Fig,  2. 

A  girl,  16  years  old,  has  been  hoarse  ever  since  she  had  diphtheria, 
nine  years  ago.  Although  she  is  slender  and  delicate,  and  rather  pale, 
heart-  and  lung-examination  reveals  notliing  abnormal ;  the  slight 
degree  of  anemia  may  perhaps  be  explained  by  her  previous  residence 
in  an  educational  institution.  The  voice  is  almost  without  sound;  air- 
waste  during  phonation  is  plainly  pei'ceptible. 

On  examining  the  larynx  (\vhich  is  oblique)  we  are  at  once 
struck  by  the  cadaver  position  of  the  left  vocal  cord.  It  is^also 
much  narrower  and  somewhat  paler  than  its  fellow.  The  free 
edge  is  slightly  concave  and  curves  outward. 

During  phonation  it  remains  immovable,  while  the  right  is 
approximated.  At  the  same  time  the  right  vocal  process  is 
seen  to  spring  forward.  On  the  left  side  the  upper  part  of  the 
posterior  wall  appears  somewhat  narrowed. 

The  picture  is  unmistakable : 

Paralysis  of  the  Left  Recurrent  Nerve,  with  Secondary  Atrophy  of 
the  Paralyzed  Muscles. 

Fig.  3. 

A  gentleman,  47  years  old,  was  infected  with  syphilis  twenty-one 
years  ago,  and  has  since  had  depositions  in  the  testicles,  in  the  muscles 
of  the  upper  arm,  and  in  the  palm,  which  always  yielded  to  potassium 
iodid. 


Five  months  ago  he  caught  a  bad  cold  and  became  suddenly  hoarse. 
He  also  had  pains  radiating  toward  the  right  ear ;  the  pains  disappeared 
under  potassium  iodid  and  local  application  of  mercurial  ointment  to 
the  throat ;  the  hoarseness,  however,  remained. 

At  the  present  time  there  are  at  both  angles  of  the  mouth  white, 
wrinkled  condylomata,  raised  above  the  surface,  not  detachable,  which 
do  not  bleed  on  being  touched.  On  the  inner  aspect  of  the  right  thigh, 
over  a  vein,  which  can  be  seen  and  felt  to  be  slightly  thickened,  there  is 
a  stripe-like,  slightly  abraded  sore. 

In  the  larynx  the  right  vocal  cord  appears  not  a  little  nar- 
rowed from  the  overlianging,  hypertrophied  ventricular  band, 
The  latter  is  rough  and  yellowish-gray  at  the  edge  and  on  the 
surface,  especially  in  its  posterior  haff. 

The  movements  of  the  vocal  cords  are  uniform  and  sufficient. 

The  nature  of  the  disease  is  not  easy  to  determine.  The  patient's  age 
and  the  persistence  of  infiltration-phenomena  in  spite  of  antiluetic 
treatment  arouse  a  suspicion  of  malignant  growth.  But  the  fact  that 
other  sypliilitic  or  postsyphilitic  symptoms  on  the  body  (leukoplakia 
and  psoriasis)  have  resisted  the  treatment  argues  against  this  theory. 
As  it  sometimes  happens  that  just  such  chronic  forms  only  heal  a  long 
time  after  the  treatment  has  been  discontinued,  the  diagnosis  will 
depend  on  the  subsequent  course  of  the  disease. 

Two  months  later  the  larynx  had  practicallj'^  regained  its  normal 
appearance.     We  therefore  had  to  deal  with 

Remains  of  Syphilitic  Ulcers. 


PLATE   14. 

Fig.  I. 

A  man,  34  years  of  age,  had  a  chancre  four  years  ago,  the  nature  of 
which  was  abundantly  explained  by  a  subsequent  exanthema.  Ten 
months  ago  the  skin  affection  broke  out  afresh,  and  since  then  he  has 
had  pain  in  the  throat  and  hoarseness,  with  occasional  aphonia. 

The  voice  is  raucous. 

The  fauces  present  a  diffuse  redness. 

The  larynx  as  a  whole  is  also  injected.  The  ventricular  bands 
are  so  swollen  that  the  vocal  cords  appear  to  be  narrowed. 
The  latter  are  also  red  throughout  their  whole  extent,  and  on 
the  anterior  third  of  their  inner  margins  -are  smooth,  flap-like 
prominences. 

The  latter  become  still  more  prominent  in  phonation.  The  disease  is 
unquestionably  of  a  syphilitic  natui^e,  and  the  only  question  that  re- 
mains is  :  To  what  pathological  category  does  this  picture  belong?  We 
evidently  have  here  not  mere  swellings,  but  true  hyperplasite.  They 
are  distinguished  from  ordinary  condylomata  by  their  absolutely  smooth 
surface  without  epithelial  alterations.  Remembering  that  such  inflam- 
matory neoplasms  may  develop  in  the  soil  of  a  chronic  catarrhal  irrita- 
tion, although  usually  found  in  other  situations,  we  describe  these  for- 
mations as 

Connective-tissue  Hyperplasise  from  Protracted  Syphilitic  Catarrh; 

that  is  to  say,  as  postsyphilitic. 

Fig.  2. 

A  lady,  32  years  old,  presents  herself  with  a  feeble,  very  hoarse,  tone- 
less voice. 

This  hoarseness  has  lasted  for  six  months,  according  to  the  patient's 
statement,  since  a  local  application  to  the  larynx ;  before  that  event 
there  had  been  occasional  improvement  in  the  voice.  For  several  years 
she  has  had  frequent  coughing-spells  without  apparent  cause  and  with- 
out being  able  to  expectorate. 

Patient  is  apparently  in  a  flourishing  state  of  health.  The  posterior 
wall  of  the  pharynx  is  granulated  and  the  pillars  are  hypertrophied. 
Irritation  of  these  parts  with  a  sound  is  immediately  followed  by  spas- 
modic cough. 

Larynx, — The  left  vocal  cord  is  smooth  and  somewhat  red- 
dened, the  anterior  two-thirds  of  the  inner  edge  slightly  curved 
outward.  The  right  cord  is  pale  yellow,  the  entire  surface 
slightly  granulated,  and  at  the  boundary  between  the  anterior 
and  middle  thirds  of  the  free  border  there  is  a  flat,  rounded, 
double  eminence  about  the  size  of  a  millet-seed. 


During  phonation  this  eminence  interferes  with  the  approximation 
of  the  cords,  so  that  a  gap  remains  at  the  rear.  If  the  hand  is  held 
before  the  mouth  during  phonation,  the  outgoing  current  of  air  can  be 
felt  (phonatory  air- waste).    The  diagnosis  is 

Benign  Neoplasm  of  the  Vocal  Cord. 

The  microscopic  picture  after  extirpation  confirms  the  diagnosis. 

Fig.  3. 

A  man,  59  years  old,  has  been  hoarse  for  the  past  two  years,  but  has 
never  had  any  pain  or  dyspnea.  The  voice,  besides  being  hoarse,  easily 
breaks  into  a  falsetto. 

The  larynx  is  pale.  On  the  left  side,  above  and  below  the 
vocal  cords,  of  which  only  a  narrow  strip  is  visible,  are  two 
nodular  tumors  of  fairly  uniform  thickness  and  pale,  grayish- 
red  color. 

During  phonation  the  left  true  vocal  cord  remains  immovable  in 
cadaveric  position. 

The  middle  of  the  left  plate  of  the  thyroid  cartilage  is  slightly  rough 
to  the  touch.     No  glands  can  be  felt. 

Heart  and  lungs  show  no  changes  but  those  due  to  age. 

Infection  is  denied. 

The  age  of  the  patient,  the  appearance  of  the  tumor,  the  sound  por- 
tion surrounded  by  proliferations,  the  infiltrations  of  the  deeper  parts 
about  the  joint  as  proved  by  the  fixation  of  the  true  vocal  cord,  and  the 
evident  participation  of  the  thyroid  cartilage  itself  on  the  one  hand  and, 
on  the  other,  the  absence  of  any  symptoms  or  data  pointing  to  a  syphil- 
itic or  a  tuberculous  infection,  induce  us  to  describe  the  tumor  as  a 
malignant  one,  most  probably 

Carcinoma. 

Experimental  excision  with  a  view  to  operation  was  not  permitted. 


Tab.   14. 


riff.i. 


<Mmm 


Fin  ? 


Fixf,J. 


Tab.   15. 


Fw.l. 


Fi(f.'-i 


I  ,il,     i//v/    !■   Nri'iil,,,!,!    \fiinilirn 


PLATE   15. 

Fig.  I. 

A  man,  oQ  years  of  age,  presents  himself  for  examination  on  account 
of  dyspnea  and  asthmatic  attacks.  Although  a  well-developed  emphy- 
sema with  chronic  bronchial  catarrh  is  recognized  as  a  sufficient  cause 
for  these  symptoms,  the  patient's  voice  is  so  rough  and  discordant  that 
the  disturbance  cannot  be  wholly  attributed  to  the  accompanying 
chronic   hyperemia   of  the   upper   air-passages. 

Laryngoscopy  reveals  the  cause  in  a  round,  shining,  white 
tumor,  as  hirge  as  the  head  of  a  pin,  situated  on  the  free  border 
of  the  rigiit  vocal  cord,  at  the  boundary  between  tlie  anterior 
and  middle  thirds.  Tlie  cord  is  rather  inflamed  and,  on  the 
whole,  somewhat  broader  than  its  fellow. 

The  movements  are  not  affected,  the  disturbance  being  due  to  en- 
croachment by  the  tumor  on  the  rima  glottidis.  Its  peculiar  appear- 
ance, the  patient's  age,  and  the  comparatively  short  duration — six 
months — of  the  hoarseness,  lead  us  to  suspect  a  malignant  growth.  A 
trial  extirpation,  penetrating  to  apparently  healthy  tissue,  proves  quite 
reassuring,  as  shown  in  PI.  33,  Fig.  3.    It  is,  therefore,  a 

Hard  Wart. 

The  future  course  of  the  disease  must,  however,  be  carefully  watched. 

Fig.  2. 

A  robu&t  man,  32  years  of  age,  has  noticed  an  alteration  in  his  voice 
for  the  past  year.  At  the  present  time  it  is  deep,  rough,  and  vibrating, 
sometimes  almost  toneless. 

The  larynx  is  normal  except  for  a  grayish-white,  shining 
eminence  on  each  vocal  cord.  The  tumors  are  exactly  equal 
in  size,  about  half  as  large  as  a  lentil,  and  placed  exactly 
opposite  each  other,  partly  on  the  free  border  and  partly  on  the 
upper  surface  of  the  respective  vocal  cord,  at  the  boundary 
between  the  middle  and  anterior  thirds.  The  remaining  por- 
tions of  the  cords  are  slightly  inflamed. 

During  phonation  the  posterior  part  of  the  glottis,  of  course,  stands 
wide  open,  as  complete  approximation  is  prevented  by  the  intervening 
tumors. 

In  the  entire  absence  of  other  symptoms  of  disease,  and  in  view  of  the 
bilateral  distribution  of  the  tumors,  -^-e  are  justified  in  pronouncing 
them  innocent  connective-tissue  neoplasms  ;  that  is  to  say, 

Edematous  Fibromata. 

Microscopic  examination  later  showed  that  the  edema  had  progressed 
to  complete  cyst- formation  (PI.  39,  Fig.  1). 


PLATE   16. 
Fig.  I. 

A  man,  24  years  old,  complains  of  hoarseness  and  aphonia.  After 
much  laborious  coughing  he  sometimes  succeeds  in  expectorating  small, 
dried  masses  of  secretion. 

The  mucous  membranes  of  the  fauces  are  hypertrophied  and  of  a 
dusky-red  color. 

Behind  the  pillars  and  in  the  posterior  nares  some  grayish-yellow, 
mucous  secretion  is  seen.  The  isthmus  is  tilled  up  by  the  hypertrophied 
tonsils.  A  similar  thick  secretion  covei*s  the  floor  of  the  nose ;  the  pos- 
terior extremities  of  both  inferior  turbinate  bones  are  enlarged. 

A  dusky-red  discoloration  pervades  the  entire  interior  of  the 
larynx,  especially  the  vocal  cords.  The  latter  are  thickened 
and  of  a  rounded  form,  the  left  more  so  than  the  right.  A  re- 
ceding fold  of  mucous  membrane  rises  high  above  the  left  vocal 
process  in  such  a  way  as  to  make  it  appear  double.  It  is  the 
typical  picture  of 

Pachydermatous  Swelling. 

The  inflammation  which  produced  the  condition  was  evidently  caused 
by  pus  from  the  nose  and  fauces. 

Fig.  2. 

A  woman,  36  years  old,  lost  her  voice  six  weeks  ago.  On  being  closely 
questioned  she  admits  that  she  had  been  hoarse  for  some  time  previous. 
No  expectoration,  but  a  good  deal  of  irritative  cough  and  pain  in  the 
right  ear  on  swallowing.  The  mother  died  of  some  throat-trouble  and 
a  sister  was  "  scrofulous  "  when  she  was  young.  The  patient  herself  had 
an  attack  of  pleurisy  two  years  ago.  She  is  of  rather  slight  build,  but 
not  especially  thin.  Examination  of  tlie  chest  gives  markedly  impaired 
resonance  over  the  right  base,  and  the  right  apex  is  somewhat  depressed. 
At  this  point  there  is  a  slight  friction-sound  in  both  inspiration  and  ex- 
piration, which  does  not  appear  after  coughing;  the  respiratory  murmur 
over  the  lower  area  of  impaired  resonance  is  weak,  but  vesicular. 

Larynx. — The  color  of  the  epiglottis  and  of  the  aperture 
appears  somewhat  darker  than  normal.  The  left  ventricular 
band  is  irregularly  swollen  and  inflamed.  The  vocal  cord  of  the 
same  side  presents  similar  alterations,  except  that  the  process 
has  gone  on  to  distinct  nodule-formation.  The  right  vocal  cord 
appears  divided  into  two  parts  by  a  discolored  ulcer  running 
lengthwise  of  the  cord  and  especially  marked  on  the  surface. 
The  edges  are  also  hypertrophied  and  covered  with  nodules. 

This  ulcer,  the  origin  of  which  can  easily  be  traced  to  decu- 
bital softening  of  a  former  infiltration,  associated  with  the 
nodular  form  of  the  latter,  is  very  characteristic  of 

Infiltrative  and  Ulcerative  Tuberculosis. 


Tab.   16. 


Tig.l 


Fie,.  3. 


Lull .  Ansf  /•:  Reuhhold.  Mimchgn . 


Tab.   17 


Fifj.l 


b.  /Ai  (  jk 


Fiff.Ji. 


Rf*ir/ihi>[tl  Miijii! 


PLATE   17. 

Fig.  I. 

A  man,  45  years  old,  has  had  dyspnea  for  the  past  few  months ; 
his  voice  became  rough  before  the  dyspnea,  which  has  been  growing 
steadily  worse,  developed.  The  patient  appears  strong,  although  thin, 
with  slight  cyanosis  of  nose,  ears,  chin,  and  fingers.  There  is  audible 
inspiratory  stridor  after  violent  exercise.  The  voice  is  rough  and  rumb- 
ling. No  areas  of  dulness  in  the  lungs;  some  emphysema  and  dry 
catarrh.  Arterial  sclerosis ;  heart  somewhat  enlarged.  The  mucous 
membranes  are  pale  and  slightly  livid. 

The  same  pallor  in  the  larynx.  The  rima  glottidis  is  ex- 
tremely narrow,  the  vocal  cords  almost  meeting  in  the  middle 
line.  A  pale  strip  of  tissue  projects  from  under  the  left  cord, 
along  the  processus  vocalis.  Behind  this  a  broad,  pale,  rather 
shiny  eminence  is  seen  projecting  from  the  posterior  wall.  (In 
phonation  the  right  cord  is  drawn  over  to  the  left,  which  is  com- 
pletely immovable ;  the  same  thing  happens  with  the  arytenoid 
cartilages.     Palpation  of  the  larynx  gives  nothing  abnormal.) 

That  this  is  not  a  palsy  appears  from  the  mobility  of  the  right  cord 
and  the  position  of  the  left ;  we  have  to  deal,  therefore,  with  an  abnor- 
mal fixation  of  both  vocal  cords,  which  must  be  due  to  inflammatory  or 
swelling-infiltration  ;  in  other  words,  to  destruction  of  the  articular  sur- 
faces. The  arytenoid  cartilages  are  probably  not  involved,  as  there  is  no 
swelUng  over  them ;  we  therefore  assume  disease  of  the  cricoid  car- 
tilage, preferably  of  the  left  side.  The  superficial  wheals  do  not  re- 
semble neoplastic  formations,  but  point  rather  to  a  chronic  inflammatory 
process. 

The  choice  lies  between  tuberculosis  and  syphilis,  and  we  decide  in 
favor  of  the  former ;  it  is  evident  from  the  steady  development  of  the 
symptoms  that  the  process  is  still  going  on,  while,  if  it  were  syphilitic, 
it  would  have  produced  more  marked  signs  of  inflammation  and  de- 
struction. While  awaiting  further  developments  we  are,  therefore,  justi- 
fied in  assuming 

Tuberculous  FericlioiLdritis  of  the  Cricoid  Cartilage. 


Fig.  2. 

An  unmarried  woman,  38  years  old,  has  been  troubled  with  shortness 
of  breath  on  going  up  stairs  for  the  past  two  years,  and  lately  the 
dyspnea  has  become  very  severe. 

Five  years  ago  she  had  typhoid  fever,  and  her  voice  was  bad  for  a  long 
time  afterward. 

Loud  stridor  is  heard  during  inspiration,  a  somewhat  softer  breathing- 
sound  during  expiration.  The  face  is  somewhat  bloated,  not  cyanotic,  but 
pale.  The  voice  is  loud  and  pure,  and  only  occa.sionally  a  little  hoarse. 
The  larynx  moves  up  and  down  during  respiration ;  the  posture  of  the 
Jiead  is  normal. 


The  base  of  the  tongue  is  crossed  by  bluish-red,  dilated 
vessels;  the  mucous  membrane  of  the  larynx  as  a  whole  is  pale. 
The  vocal  cords  are  slightly  injected  and  in  the  cadaver-position. 
Two  pale-red  bands,  of  the  same  width  as  the  vocal  cords,  project 
from  under  them,  curving  a  little  outward  in  the  back  part 
of  the  glottis.  These  bands  have  thin,  uneven  edges  and  a 
smooth  surface,  and  extend  almost  continuously  to  the  anterior 
portion  of  the  cricoid  cartilage. 

During  phonation  tlie  cords  are  perfectly  approximated,  while  the 
subcordal  bands  remain  immovable. 

The  lungs  present  only  a  little  enlargement;  heart,  etc.,  normal.  No 
swollen  glands,  nothing  suspicious  in  the  anamnesis.  The  neoplasm 
may  be  either  malignant  in  character  or  it  may  be  due  to  chronic 
plastic  inflammation.  Although  the  bilateral  distribution  does  not 
exclude  the  former,  yet  the  movabihty  of  the  vocal  cords,  at  least 
toward  the  middle  line,  argues  against  it.  Further  observation  showed 
no  increase  in  size.    It  was  a 

Stenosis  from  Chronic  Perichondritis  of  the  Cricoid  following 
Typhoid  Fever. 


PLATE  18. 

Fig.  I. 

A  roDUst  man,  28  years  old,  has  been  hoarse  for  six  months.  No 
other  symptoms.    Syphilis  denied.    Lungs  and  heart  normal. 

The  entire  larynx  presents  the  picture  of  chronic  infiamma- 
tion.  The  vocal  cords  in  particular  are  thickened  and  of  a 
dark-red  color.  The  center  of  the  left  cord  is  covered  by  a 
smooth,  dark-red,  spindle-shaped  tumor  which  extends  to  the 
ventricular  band.  The  tumor  appears  to  be  seated  imme- 
diately upon  the  vocal  cord,  like  an  extinguisher. 

It  is  small  and  can  easily  be  pushed  aside  with  a  sound,  so  that  it 
almost  disappears  under  the  ventricular  band  in  the  ventricle  of  Mor- 
gagni.  Everything  points  to  an  inflammatory  origin.  It  is  the  relaxed 
and  hypertrophied  mucous  membrane  of  the  under  surface  of  the  ven- 
tricular band  which  has  prolapsed,  presenting  the  picture  of 

Prolapse  of  the  Ventricle  of  Morgagni. 

Fig.  2. 

A  woman,  58  years  old,  has  been  hoarse  for  eight  years ;  often  she 
loses  her  voice  entirely.    No  other  symptoms. 

The  voice  is  rough  and  low,  easily  breaks  into  falsetto,  and  is  produced 
with  great  difficulty. 

The  larynx  is  very  large.  A  very  red,  smooth,  semi-elliptical 
tumor,  with  blood-vessels  ramifying  over  its  surface,  projects 
from  the  right  ventricle  of  Morgagni  and  covers  the  greater 
part  of  the  vocal  cord. 

In  phonation  the  tumor  is  held  against  the  left  ventricular  band. 
Examination  with  a  sound  reveals  a  broad  base,  seated  upon  the  upper 
surface  of  the  vocal  cord. 

Both  the  appearance  and  the  seat  of  the  neoplasm,  as  well  as  the  ex- 
ternal conditions,  attest  its  innocent  nature.    It  is  a 

Soft  Fibroma. 

Subsequent  microscopical  examination  confirms  the  diagnosis. 

Fig.  3. 

A  gentleman,  38  years  old,  who  has  been  treated  for  syphihtic  ulcers 
in  the  throat,  complains  of  hoarseness  and  a  feeling  of  dryness  in  the 
throat  for  some  weeks. 

The  epiglottis  is  slightly,  the  right  vocal  cord  intensely  in- 
flamed ;  the  surface  of  the  latter  also  exhibits  areas  of  j'ellow- 
ish  discoloration.    The  most  anterior  portion  of  the  vocal  cords, 


and  epecially  the  anterior  half  of  the  ventricular  bands,  are 
overshadowed  by  a  smooth,  dark-red,  semi-elliptical  tumor, 
which  apparently  springs  from  the  posterior  surface  of  the 
epiglottis. 

Although  tlie  tumor  looks  very  much  like  an  innocent  neoplasm,  yet 
the  unilateral  character  of  the  inflammation  and  the  destruction  of 
epithelium  show  tliat  a  more  complicated  process  is  going  on— first  infil- 
trative, then  destructive — and  the  diagnosis  of 

Tertiary  SypMlitic  Depositions 

finds  further  support  in  the  anamnesis. 


Tab.   18. 


Fi(^.l 


Fig.Ji. 


tiff.'i. 


Uth.Anst  F.  Reidihold,  Miindien. 


Tab.   19. 


F,f,.l 


Fig.S. 


Fig.,3. 


LUh^  Anst  F.  Retrhhxtld,  Miinchen 


PLATE   19. 
Fig.  I. 

A  gentleman,  30  years  old,  complains  of  stabbing-pains  in  the  right 
side  of  the  throat,  felt  on  swallowing  and  when  he  wakes  up.  No  cough 
or  fever.  The  symptoms  began  a  week  ago,  when  the  patient  took  cold 
after  dancing.  He  also  remembers  that  he  swallowed  a  large  piece  of 
candy  whole. 

The  region  of  the  right  crico-arytenoidean  articulation  is  painful  to 
pressure  from  the  outside.  The  throat  shows  no  swelling  or  inflamma- 
tion. 

Larynx. — A  broad,  red  eminence,  capped  with  a  yellowish 
discoloration,  protrudes  over  the  posterior  extremity  of  the  right 
vocal  cord  in  the  region  of  the  upper  surface  of  the  right  car- 
tilage of  Wrisberg. 

The  probe  meets  with  no  abnormal  resistance,  nor  does  anything  else 
point  to  the  presence  of  a  foreign  body.  The  mobility  of  the  right  vocal 
cord  and  the  voice  itself  are  unimpaired.  All  the  symptoms  disappeared 
within  a  week  with  no  other  treatment  than  rest.  The  only  possible 
diagnosis,  therefore,  is 

Circumscribed  Inflammation  with  Abscess-formation 

of  unknown  origin,  probably  of  a  traumatic  nature. 

Fig.  2. 

A  strongly  built  man,  27  years  old,  has  had  attacks  of  convulsive 
cough  for  a  week  ;  no  expectoration,  or  at  most  a  trace  of  gray  mucus. 
Nothing  abnormal  in  nose,  throat,  or  lungs. 

The  entire  larynx  is  slightly  inflamed.  The  redness  of  the 
posterior  wall  is  particularly  noticeable ;  on  it  are  seen  two  flat 
prominences  more  intensely  colored  than  the  surrounding 
surface. 

The  patient  was  examined  a  short  time  ago  and  nothing  of  the  kind 
was  visible,  so  that  these  formations  must  be  of  acute  origin.  The  con- 
vulsive cough  is  also  very  characteristic  of 

Acute  Interarytenoid  Laryngitis. 

Fig.  3. 

A  pale,  thin  girl  of  23  says  she  has  noticed  a  loss  of  tone  in  her  voice 
for  the  past  three  months  ;  she  has  also  lost  strength  and  perspires  very 
easily.  Little  cough  and  no  expectoration.  The  mother  died  of  some 
lung-disease. 

Conjunctivse,  mouth,  and  throat  are  very  pale.  Chest  narrow,  with 
slight  respiratory  movement ;  auscultation  reveals  no  areas  of  impaired 


resonance  or  other  abnormal  signs,  only  the  breath-sounds  are  very  faint. 
Heart-dulness  a  little  smaller  than  normal ;  pulse  85,  and  weak. 
Nothing  abnormal  in  nose  or  fauces. 

The  larynx  in  general  is  rather  pale ;  the  posterior  wall  ex- 
hibits a  slight  jagged  dentation  ;  to  the  left  of  the  petiolus  of  the 
epiglottis  the  tissues  are  slightly  inflamed  and  hypertrophied. 

It  is  only  by  great  eflbrt  that  an  apjDroximate  closure  of  the 
glottis  is  brought  about. 

Tliis  want  of  tone  in  the  muscles  shows  that  the  inflammation  of  the 
epiglottis  and  the  formation  of  the  posterior  wall  are  not  due  to  mere 
irritation  of  the  mucous  membrane  from  external  causes,  but  correspond 
to  the 

First  Stage  of  Tuberculous  Infiltration. 

The  positive  value  of  these  findings  is  not  diminished  by  the  failure 
to  determine  the  presence  of  lung-disease,  and  is  furthermore  supported 
by  the  general  decline  of  the  entire  body. 


PLATE  20. 

Figs.  I  and  2. 

The  patient  mentioned  in  the  preceding  history  died  soon  afterward 
of  hemorrhage  from  the  lungs. 

Fig.  1. — The  larynx  is  opened  from  the  front ;  in  the  middle 
of  the  posterior  wall  is  a  small  ulcer,  hardly  as  large  as  a  lentil, 
with  raised,  slightly  nodular  edges ;  the  floor  is  of  a  grayish- 
green.  (The  edges  appear  flatter  in  the  cadaver  than  in  the 
living  subject.)  After  making  two  lateral  incisions  it  is  found 
that  the  destruction  is  much  more  extensive  than  was  supposed. 

Fig.  2. — The  mucous  membrane  is  extensively  undermined 
beyond  the  domain  of  the  arytenoid  cartilages.  The  floor  of 
the  ulcer  presents  a  grayish-green  discoloration  and  is  covered 
with  a  scanty,  thin,  purulent  secretion. 

Palpation  with  the  finger  and  with  the  sound  shows  that  the  floor  of 
the  ulcer  is  hard  and  rough ;  the  cartilage  is  therefore  exposed  and 
eroded  and  at  tlie  same  time  converted  into  bone.  It  is  the  usual  process 
in  tuberculosis — 

Ossifying  and  Rarefying  Fericliondritis  and  Chondritis. 


o 

si 
Eh 


I 


=^-^ 
•^ 


Tab.  21 


Firj.l. 


Fiff.. 


Fuf.'i. 


I  111,     ;/,./    F  T}pirhhi)hl     \ 


PLATE  21. 
Fig.  I. 

A  man,  35  years  old,  has  had  cough  for  the  past  three  months ;  in  the 
last  two  weeks  he  has  also  had  pain,  both  spontaneous  and  on  swallow- 
ing.   No  expectoration. 

There  is  marked  pallor  and  impaired  nutrition.  The  chest  is  flat; 
the  right  apex  is  depressed,  resonance  is  impaired,  and  there  is  accen- 
tuated, prolonged  expiration. 

The  heart  is  small  and  its  action  weak.  On  the  breast  are  several 
radiating  scars. 

A  rough,  sharp-pointed  eminence  with  a  broad  base  springs 
from  the  center  of  the  posterior  wall.  The  mucous  membrane 
at  the  back  of  the  epiglottis  over  the  petiolus  is  intensely  in- 
flamed ;  in  the  center  of  this  zone  is  a  yellowisli-gray  discolored 
ulcer  with  smooth,  straight  edges. 

Although  the  general  condition  of  the  entire  body  and  of  the  lungs  is 
in  perfect  accord  with  the  lesion  in  the  posterior  wall,  which  exhibits 
the  typical  appearance  of  tuberculous  hyperplasia,  the  ver>'  acute  course 
of  the  ulcer,  without  infiltration  of  the  surrounding  tissue,  argues  against 
tuberculosis. 

Upon  being  more  closely  questioned  the  patient  admits  that  he  was 
infected  a  year  ago,  and  had  a  rash  and  pustules  on  the  breast,  so  that 
our  suspicion  of  syphilis  is  confirmed.  At  the  same  time  this  does  not 
influence  our  judgment  as  to  the  nature  of  the  infiltration  in  the  pos- 
terior wall.    We  have  two  processes  going  on  side  by  side, 

Tuberculosis  and  Active  Tertiary  Syphilis. 

The  diagnosis  is  confirmed  by  the  subsequent  course  of  the  disease. 


Fig.  2. 

A  woman,  25  years  old,  seeks  relief  for  entire  aphonia.  She  says  she 
is  not  sick  otherwise  except  for  "a  slight  cough,"  which,  she  thinks, 
amounts  to  nothing.  It  appears,  however,  that  this  "slight  cough" 
brings  up  yellow  mucus  in  considerable  quantities.  The  father  died 
of  " inflammation  of  the  lungs."  "How  long  was  he  ill?"  "Only  a 
year  and  a  half."    The  husband  is  well ;  two  children  always  sickly. 

The  patient  is  strongly  built  but  decidedly  emaciated.  Breathing'  is 
superficial.  Respiratory  movement  impaired  on  the  right  side.  A 
somewhat  shortened  note  over  both  apices,  more  on  the  right  side  than 
on  the  left.  Over  the  right  base  behind,  a  little  inside  of  the  scapular 
line,  is  a  zone  of  high-pitched  tympanitic  note.  In  the  same  situation 
loud  sonorous  rales  and  bronchial  breathing.  Over  the  apices  accentu- 
ated inspiration  and  interrupted  expiration.  The  fauces  are  very  pale; 
the  gums  retracted. 

Larynx. — The  anterior  surface  of  the  right  arytenoid  cartil- 
age is  converted  into  two  small,  pale  prominences.     A  thickish, 


PLATE   22. 

Fig.  I. 

A  woman,  47  years  old,  afflicted  with  advanced  tuberculosis  of  the 
lungs,  comes  to  be  treated  for  dyspnea  and  total  loss  of  voice.  The 
dyspnea  can  hardly  be  explained  by  the  lung-disease  alone.  She  does 
not  complain  of  pain  on  swallowing,  but  the  epiglottis  frequentlj'  fails 
to  protect  the  larynx  from  the  entrance  of  foreign  matters. 

The  larynx  in  general  is  rather  pale — a  yellowish -gray.  A 
rough,  brownish-yellow  tumor  springs  from  the  free  edge  of  the 
right  vocal  cord ;  it  is  rather  flat  and  apparently  very  dense, 
and  the  line  of  demarcation  from  the  surrounding  healthy 
tissue  is  indistinct.  A  similar,  though  much  larger  tumor,  in 
shape  like  a  blunt  pyramid,  arises  between  the  two  arytenoid 
cartilages.  The  posterior  wall  is  uniformly  hypertrophied,  its 
left  outline  being  somewhat  irregular. 

The  movements  are  very  slow  in  phonation,  as  if  all  the  parts  were 
rigid,  showing  that  the  infiltration  is  tough.  The  appearance  of  the 
alterations  alone,  without  regard  to  the  condition  of  the  lungs,  tells  the 
experienced  observer  that  he  has  to  deal  with 

Tuberculous  Tumors  and  Tuberculous  Infiltration. 


Fig.  2. 

A  man,  28  years  old,  seeks  relief  for  constant  hoarseness.  Three 
months  ago  he  went  through  an  antisyphilitic  cure  for  indurated  ulcer. 
Mouth  and  throat  are  free  from  symptoms. 

In  the  larynx  there  is  a  smooth,  dark-red  tumor,  shaped  like 
the  segment  of  a  sphere,  bulging  out  from  the  posterior  w^all 
far  down  under  the  glottis. 

The  tumor  may  immediately  be  pronounced  a 

Gumma  on  the  Anterior  Plate  of  the  Cricoid  Cartilage, 

for  it  is  evident  from  the  hoarseness  that  the  infiltration  must  extend 
deeply. 

The  diagnosis  is  confirmed  by  the  rapid  disappearance  of  the  tumor 
with  the  use  of  potassium  iodid. 


Fig.  3. 

A  man,  32  years  old,  was  treated  a  year  ago  for  syphilis  of  the  palate 
and  nose.  The  ulceration  was  followed  by  a  tedious  secondary  sup- 
puration of  the  no.se,  tl)e  secretion  pouring  itself  into  the  throat  ex- 
clusively. The  voice,  which  had  been  fairly  good,  has  become  very 
rough  in  the  last  three  months. 


Tab.  22. 


Fiff.l. 


Fig.  2. 


Fi-f/.J. 


Tab.  23. 


Figl. 


Fifi 


LlJh..yn.>i    .    >'-'-r>>hnhl   Munrlu'U. 


PLATE  23. 

Fig.  I. 

A  man,  40  years  old,  comes  to  us  in  the  Spring  with  a  history  of  dry- 
ness in  the  throat  and  roughened  voice,  which,  he  says,  began  with  the 
cold  weather  and  persist  obstinately.  Occasionally  he  is  troubled  with 
convulsive  cough.     The  throat  is  slightly  inflamed. 

The  larynx  is  rather  pale.  Tlie  region  below  the  apex  of  the 
left  arytenoid  cartilage  is  somewhat  hypertrophied ;  in  front 
the  hypertrophy  merges  into  a  red,  granular  tumor  with  a  broad 
base  and  apparently  of  a  dense  consistence,  ending  in  a  fairly 
sharp  point. 

The  movement  of  the  left  cord  is  imperfect  and  the  closure  of  the 
glottis  is  not  complete.  Exploration  with  a  sound  shows  that  the  tumor 
is  very"  hard.  The  lungs  are  apparently  normal.  Nothing  suspicions  in 
the  family  history,  but  the  patient  says  he  has  lost  strength  considerably. 

The  last-mentioned  circumstances  confirm  the  suspicion,  based  on  the 
granular  appearance  and  dense  consistence  of  the  tumor  and  on  the 
probability  that  the  infiltration  extends  more  deeply,  that  the  disease  is 

Hyperplastic  Tuberculosis. 

Further  confirmation  is  furnished  by  trial  curettage  and  microscopic 
examination. 

Fig.  2. 

A  woman,  26  years  old,  has  been  hoarse  for  the  past  six  weeks,  and  in 
the  course  of  the  last  few  days  severe  dyspnea  has  been  superadded.  She 
also  has  pains  radiating  to  the  left  ear. 

The  body  appears  badly  nourished ;  the  color  of  the  skin  is  a  dirty 
white.  Inspiratory  stridor.  Great  tenderness  on  pressure  at  the  upper 
and  back  part  of  the  left  thyroid  cartilage.  The  glands  under  the  angle 
of  the  jaw  and  in  the  neck  are  swollen  on  both  sides,  but  only  the  left 
cervical  glands  are  painful.  The  speech  is  entirely  aphonic.  The  hair 
has  been  dropping  out  fast  lately.  Xo  birth,  no  abortion.  The  patient 
cannot  recall  any  personal  or  family  disease. 

Only  the  (posterior)  margin  of  the  epiglottis  retains  its 
normal  yellow  color ;  from  that  point  to  the  line  of  version  the 
injection  of  the  tissues  becomes  more  and  more  marked  and 
culminates  in.  a  deep,  dark-red  discoloration.  The  mucous 
membrane  of  the  posterior  wall  is  red  and  swollen  on  the  right 
side  ;  on  the  left  the  swelling  has  resulted  in  the  formation  of  a 
grayish-red,  shiny  sac  (edema).  The  left  vocal  cord  is  in  the 
cadaver-position  and  immovable  during  phonation,  as  is  the 
entire  region  of  the  arytenoid  cartilage. 

We  have  all  the  signs  of  an  acute,  far-reaching  inflammatory^  process, 
showing  that  the  immobility  of  the  left  side,  which  is  considerably  more 


Lungs  are  intact ;  glands  not  swollen  ;  syphilis  denied.  The  process 
is  evidently  a  chronic  one,  dependent  anatomically  on  some  grave  dis- 
turbance of  the  motile  apparatus,  as  the  posture  of  the  vocal  cords  shows. 
Whether  this  disturbance  is  in  the  muscles  or  in  the  cartilages,  is  hard 
to  decide,  as  the  posture  corresponds  to  paralysis  of  the  posterior  crico- 
arytenoid muscles.  Nor  is  it  quite  clear  if  inflammation  or  a  new 
growth  is  at  the  bottom  of  the  trouble.  The  appearances  are  more  in 
favor  of  the  former  (inflammatory  edema) ;  on  the  other  hand,  the 
irregular  surface  and  angular  form  of  the  tumor  are  rather  suspicious  of 
the  latter.  The  ulcer  also  has  no  typical  character.  In  any  case,  the 
disease  is  not  tuberculosis.  As  we  are  in  doubt,  we  resort  to  antiluetic 
treatment. 

At  first  this  treatment  is  apparently  effective,  for  after  six  weeks  the 
breathing  is  so  much  improved  that  the  advisability  of  removing  the 
cannula?  is  considered.  Meanwhile,  however,  the  appearance  of  the 
picture  is  so  much  changed  that  there  is  no  further  doubt  as  to  its  true 
nature. 

(Fig.  3.)  During  respiration  the  right  vocal  cord  still  occupies 
a  median  position,  while  the  left  is  abducted.  The  latter  is  of 
a  pale  red.  The  tumor  on  the  posterior  wall  has  diminished, 
but  is  still  quite  marked. 

Close  to  the  ulcer,  which  is  now  reduced  in  size  one-half  (?), 
on  the  median  side  is  a  pale-red,  w^avy  tumor  as  large  as  a 
lentil,  irregular  in  outline,  and  merging  into  the  larger  tumor. 

This  formation  occurs  only  in 

Malignant  Growtli. 

Microscopic  examination  of  an  extirpated  portion  shows  it  to  be  an 
alveolar  sarcoma.     (See  PI.  37,  Figs.  1  and  2.) 


Tab.  24. 


>. 


Tig.l. 


Fiq.  3, 


Fi(f.,3. 


Lilh.  Anut  t'.  HejjCh/iold,  Miinchejt 


Tab.  25. 


Fi(ll. 


Fiff.Ji. 


Fiii-fJ. 


L((h.  Afi.sf  /•:  HjeidOwUI.  Miinci 


PLATE   25. 
Fig.  I. 

A  girl,  16  years  old,  has  been  ill  for  two  days  with  headache,  fever, 
and  violent  pain  on  swallowing.  This  morning  hoarseness  and  some 
dyspnea  set  in.    Bowels  constipated. 

The  patient  is  weak,  cheeks  very  red,  respiration  short,  and  the  sen- 
sorium  is  reduced.  Pulse  110,  temperature  39.5°  C.  In  the  pharynx 
there  is  nothing  abnormal  except  a  slight  redness  of  the  posterior  wall. 
The  voice  is  toneless ;  even  the  whispered  sounds  are  very  weak. 

Larynx. — The  exnglottis  is  inflamed.  The  vocal  cords  are  a 
very  little  hyperemic  and  in  the  cadaver-position.  But  the 
posterior  wall  consists  of  two  enormously  swollen,  glistening, 
blood-red  masses  which  prevent  all  motion. 

Such  phenomena  are  produced  only  by 

Laryngeal  Erysipelas. 


Fig.  2. 

A  gentleman,  67  years  old,  who  had  formerly  always  enjoyed  good 
health,  became  very  ill  nine  months  ago  after  an  attack  of  influenza: 
fever  in  the  evening,  sweats,  loss  of  flesh,  copious  yellowish-gray  expec- 
toration, and,  in  the  last  few  months,  hoarseness  and  shortness  of  breath. 

The  body  is  still  fairly  robust,  but  the  flabby  skin  testifies  to  the  loss 
of  substance.  On  percussion  :  above  and  behind  on  both  sides  almost 
complete  dulness  ;  on  the  right  side  under  the  clavicle,  from  the  second 
to  the  fourth  rib,  dull  tj^mpanitic  note,  increased  at  the  point  where  it  is 
best  heard  when  the  mouth  is  opened.  Numerous  rales  over  the  entire 
lung;  over  the  right  apex  loud  bronchial  breathing  with  tinkling  rales. 
Posteriorly  above,  bronchial  breathing  on  both  sides  with  crackling 
rales. 

Piespiration  short,  accelerated,  and  faintly  audible. 

The  entire  larynx  is  bright  red.  The  posterior  wall  is  hyper- 
trophied  and  resembles  a  sausage.  On  the  left  side  a  smooth, 
thick  swelling  rises  from  its  anterior  surface.  The  right  vocal 
cord  is  entirely  hidden  by  the  swollen  ventricular  band ;  in  the 
region  of  the  vocal  process  the  left  appears  to  be  split  in  two; 
in  reality,  however,  it  is  a  doubling  of  the  fold  of  mucous  mem- 
brane; for  the  reason  mentioned  above  (the  thickening  of  the 
ventricular  band)  it  also  appears  narrower.  Abduction  is  evi- 
dently incomplete,  as  neither  cord  moves  beyond  the  cadaver- 
position  in  its  outward  excursion. 

The  larjmx  is  not  sensitive  to  pressure  from  the  outside.  The  voice 
is  discordant,  deep,  rough,  almost  aphonic,  and  often  changes  to  a 
whisper. 


PLATE   26. 

Fig.  I. 

A  patient,  36  years  old  (male),  afflicted  with  pulmonary  and  laryn- 
geal phthisis,  is  treated  with  a  Koch  injection.  On  the  following  day 
this  picture  is  seen. 

Both  aryteno-epiglottidean  folds,  as  well  as  the  entire  upper 
border  of  the  posterior  wall  of  the  larynx,  especially  on  the  left 
side,  are  converted  into  a  smooth,  glistening,  balloon-like  swell- 
ing. The  ventricular  bands  also  appear  hypertrophied.  In 
respiration  both  vocal  cords  are  very  near  the  middle  line, 
between  cadaveric  and  phonation-posture ;  they  are  discolored 
and  harder  than  normal,  with  rough,  uneven  edges.  A  small 
spur  projects  in  front  of  the  left  vocal  process. 

The  tumors  must  all  be  attributed  to 

Acute  Inflammatory  Edema 

over  the  tuberculous  portions. 


Fig.  2. 

An  extremely  emaciated  woman,  24  years  old,  with  hectic  flush, 
copious  purulent  expectoration,  extreme  debility — in  short,  all  the  signs 
of  advanced  pulmonary  phthisis,  which  is  furllier  confirmed  by  the 
physical  examination — is  suffering,  in  addition,  from  intense  dyspnea. 
Orthopnea  and  stridor  are  also  present  in  a  marked  degree. 

With  the  exception  of  the  epiglottis,  the  entire  larynx  is 
diseased.  The  right  vocal  cord  is  not  visible  at  all ;  of  the  left, 
only  a  small  strip  near  the  vocal  process  is  to  be  seen.  Every- 
thing else  is  hidden  by  the  ventricular  bands,  which  are  con- 
verted into  pale,  rigid,  somew^hat  uneven  tumors.  The  aryteno- 
epiglottidean  folds  are  also  very  much  hypertrophied,  grayish- 
yellow  in  color,  and  glistening  (edematous).  On  the  right  side 
is  a  broad,  club-shaped  tumor  as  large  as  a  bean  and  slightly 
nodular,  blocking  up  the  back  t)art  of  the  already  narrowed 
lumen. 

No  signs  of  degeneration,  at  least  on  the  surfaces  exposed  to 
view. 

The  presence  of  edema  in  the  posterior  portion  proves  that,  in  addi- 
tion to  the  more  superficial  lesions  which  are  at  once  recognized,  a 
deeper  morbid  process  is  at  work,  probably  in  the  cartilaginous  frame- 
work ;  it  is,  tlierefore, 

Diffuse  Tuberculous  Infiltration  of  the  Entire  Larynx  and  Tubercu- 
lous Tumor-formation. 


Tab.  26. 


Fig.!. 


FigJi. 


LUh.An.^i  /''  RpirhhnlfJ  Wirirfwri 


Tab.  27. 


FMfl. 


X^Itp^ 


Fiff.Ji. 


LUh.  Aruil  F.  Reichhjold,  Miinchf/t 


PLATE   27. 
Fig.  I. 

A  gentleman,  47  years  old,  of  robust  appearance,  has  been  sufifering 
from  increasing  dyspnea  for  the  past  year;  occasionally  he  also  experi- 
ences diflficulty  in  swallowing  solid  food. 

The  voice  is  raucous  and  easily  breaks  into  another  register ;  respira- 
tion someW'hat  stenotic. 

A  tumor  as  large  as  a  walnut  blocks  up  the  entrance  to  the 
larynx,  so  that  only  a  part  of  the  ventricular  band  and  the  ary- 
epiglottidean  fold  on  the  right  side  are  visible. 

The  tumor  is  yellowish-gray  in  color;  the  surface  lumpy  and 
irregular,  and  crossed  by  numerous  blood-vessels. 

There  is  still  some  mobility,  most  marked  in  the  anterior  portion,  so 
that  the  origin  of  the  tumor  may  be  in  the  left  arytenoid  region.  Its 
nature  cannot  be  determined  with  any  degree  of  certainty ;  in  the 
absence  of  swelling  of  the  cervical  glands  and  of  metastastes,  the  rapid 
development  perhaps  points  to  malignancy. 

Microscopic  examination  of  the  excised  tumor  shows  it  to  be  a 

Squamons  Epithelioma. 

(See  PI.  39,  Fig.  3.) 

Fig.  2. 

A  woman,  62  years  old,  has  experienced  increasing  difficulty  in  swal- 
lowing during  the  past  six  months,  and  latterly  has  been  able  to  take 
only  liquid  nourishment.  She  never  had  pain.  Has  lost  strength  a 
good  deal. 

Pale,  emaciated  subject ;  no  discoloration  of  the  skin  or  mucous  mem- 
branes. No  glands  can  be  felt  in  the  neck ;  nothing  abnormal  on  palpa- 
tion. 

The  throat  and  larynx  are  very  pale ;  the  posterior  half  of 
the  latter  is  concealed  by  a  pale,  bluish-red,  slightly  uneven 
tumor,  which  gradually  disappears  in  the  posterior  wall  of  the 
pharynx.  The  base  of  the  tumor  is  continuous  with  the  upper 
margin  of  the  larynx. 

Phonation  is  not  impeded ;  the  voice  is  weak,  but  pure.  The  tumor 
can  be  easily  moved  and  lifted  away  from  the  posterior  wall  of  the 
pharynx  with  a  sound.  Respiration  is  free ;  heart  and  lungs  present 
only  alterations  incident  to  age. 

Owing  to  the  curious  seat  of  the  tumor  and  the  age  of  the  patient,  no 
diagnosis  could  be  made  until  after  the  extirpation.  The  tumor  was 
found  to  have  a  broad  base,  resting  on  the  posterior  wall  of  the  cricoid 
cartilage.    Microscopic  examination  revealed  an 

Innocent  Connective-tissue  Neoplasm. 

(See  PI.  40,  Fig.  1.) 


PLATE   28. 
Fig.  I. 

After  suffering  for  a  year  with  "throat-catarrh  "  and  extreme  hoarse- 
ness, a  gentleman,  56  years  old,  would  like  to  have  his  throat  examined. 
He  can  barely  produce  a  feeble,  rough  sound,  and  also  has  diflficulty  in 
swallowing. 

The  general  habit  is  vigorous,  but  somewhat  anemic.  The  neck 
hangs  in  folds ;  is  not  swollen.  On  palpation  the  left  plate  of  the  thyroid 
is  found  to  be  hypertrophied  and  lumpy,  and  more  or  less  adherent  to  the 
surrounding  connective  tissue.  Two  small  glands  can  be  felt  under  the 
chin. 

Larynx. — The  epiglottis  alone  is  normal ;  it  leans  far  back- 
ward, obstructing  the  view  into  the  interior  (more  so  than  is 
represented  in  the  picture).  The  right  vocal  cord  is  slightly  in- 
flamed ;  the  left  is  replaced  by  a  rather  red,  granular  tumor  re- 
sembling a  raspberry,  which  fades  away  gradually  into  the  ven- 
tricular band.  Both  aryteno-epiglottidean  folds  are  very  much 
hypertrophied,  especially  the  left,  which  is  swollen  to  about 
double  its  natural  size  and  presents  a  shapeless,  irregular  mass. 
On  the  upper  and  anterior  surface  is  an  ulcer  of  irregular,  sinu- 
ous outline,  becoming  deeper  as  it  sweeps  backward,  with  raised 
edges  surrounding  it  like  a  rampart  and  grayish-green,  discolored 
floor. 

During  phonation  the  left  side  is  immovable,  from  which  we  may  de- 
duce that  the  infiltration  extends  deeply  and  has  involved  the  joint. 

The  infiltration  is  evidently  extensive,  and  the  true  nature  of  the 
tumor  is  clearly  shown  by  its  appearance  and  by  the  duration  of  the 
process.  It  is  evidently  a  true  neoplasm  which,  judging  by  its  extent, 
degeneration,  invasion  of  surrounding  tissues,  and  the  glandular  metas- 
tases, can  only  be  a 

Carcinoma. 


Fig.  2. 

A  man,  47  years  old,  calls  in  the  physician  for  imminent  asphyxia. 
Dyspnea  has  existed  for  some  months,  also  a  good  deal  of  cough  nnthout 
expectoration.  For  several  weeks  the  patient  has  been  able  to  swallow 
only  liquid  food. 

Extreme  emaciation,  explained  by  the  last  point  in  the  anamnesis. 
Intense  inspiratory  stridor;  expiration  very  much  prolonged,  all  the 
accessory  muscles  being  called  into  action.  Although  the  patient  is  very 
weak,  he  sits  up  straight  all  the  time,  with  head  retracted. 

Percussion  gives  marked  increase  in  lung-area ;  no  dulness  anywhere. 
Auscultation  impossible  on  account  of  the  stenotic  respiration,  which 
drowns  all  other  sounds. 

The  temperature  has  been  taken  for  several  days,  and  there  is  no  fever. 


The  larynx  as  a  whole  is  anemic  and  leaves  only  a  narrow 
cleft  for  the  passage  of  air.  The  right  vocal  cord  is  yellowish- 
white.  A  smooth,  red  band,  nearly  as  broad  as  the  cord,  lies 
directly  underneath  and  gradually  fades  away  in  the  commis- 
sure, the  anterior  part  being  slightly  swollen  at  the  edge.  The 
left  vocal  cord  at  its  middle  third  is  converted  into  a  rough, 
red  tumor,  while  the  posterior  third  is  hidden  by  another  thick, 
pale-red  growth  as  large  as  a  bean,  its  broad  base  resting  on  the 
posterior  wall,  which  is  very  much  hypertrophied. 

The  cervical  glands  are  not  swollen.  The  left  ala  of  the  thyroid  is 
somewhat  thick  and  uneven  to  the  touch,  but  not  sensitive. 

During  phonation  the  left  side  is  immovable. 

It  is  clear  from  the  anatomical  alterations  that  the  left  half  of  the 
cricoid  cartilage  is  the  principal  seat  of  the  disease.  The  subcdrdal  band, 
however,  shows  that  the  right  half  has  also  become  secondarily  in- 
volved. The  predominant  character  of  the  lesion  is  tliat  of  a  tumor ;  the 
only  inflammatory  features  appear  in  the  subcordal  band,  which  is  prob- 
ably an  inflammatory  edema  overlying  a  perichondritis.  As  the  tumor 
is  associated  with  extensive  infiltration  of  the  deeper  parts,  and  has  also 
attacked  the  cartilaginous  structure,  to  judge  from  the  fixation  of  the 
joint,  the  process  must  be  a  destructive  one.  There  are  three  possibilities : 
malignant  growth,  syphilis,  and  tuberculosis. 

There  are  many  points  in  favor  of  the  first :  the  unilateral  character 
of  the  disease,  the  patient's  age,  the  gradual  development,  the  absence  of 
general  and  pulmonary  symptoms.  There  is  nothing  either  in  the  anam- 
nesis or  in  the  results  of  physical  examination  to  suggest  syphilis;  slow, 
gradual  development  is  not  characteristic  of  that  disease.  Tuberculosis 
might  produce  a  similar  picture, — in  fact,  the  pale,  uneven  tumor  simu- 
lates that  disease  very  closely  ;  but,  on  the  other  hand,  the  intact  condi- 
tion of  one  vocal  cord  is  very  unusual  in  such  an  advanced  stage;  be- 
sides there  is  no  expectoration  and  no  fever  (the  patient  has  been  under 
observation  for  several  weeks). 

As  even  the  microscopic  examination  of  part  of  the  tumor  on  the 
true  vocal  cord  gives  no  positive  result,  we  must  be  content  with  a  pro- 
visional diagnosis  of 

Carcinoma  ? 

(See  following  plate.) 


Tab.  28. 


Ji,,.l. 


Fiff.. 


Lith. AnM  E Reichhold. Munchen. 


Tab.   29. 


Fiff.l. 


LUh.Atist  KReiJchhotd.  Miinchen. 


PLATE  29. 

To  the  foregoing  historj^  must  be  added  that,  a  few  weeks  after  traohe- 
otomy  was  perforraed,  high  hectic  fever  set  in,  the  patient  expectorated 
copiouslj'-,  and  the  sputum  contained  tubercle  bacilh.  Thus  the 
diagnosis  of 

Tuberculous  Perichondritis  of  the  Cricoid 

was  at  last  established. 

How  extensive  it  was  is  seen  by  the  result  of  the  autopsy,  held  six 
weeks  after  the  patient  first  came  under  observation. 

The  cut  surfaces  of  the  cricoid  cartilages  exhibit  a  uniform 
green  discoloration ;  the  left  side  contains  a  large  ulcerated 
cavity,  in  which  a  large  (ossified)  sequestrum  is  freely  movable. 

In  the  trachea  is  seen  the  wound  of  the  tracheotomy-tube, 
very  much  enlarged  by  suppuration  of  the  edges. 


These  data  are  too  meager  for  us  to  form  an  opinion  of  the  true  nature 
of  the  disease,  and  for  the  present  we  must  be  content  with  an  anatomi- 
cal diagnosis. 

The  process  is  evidently  an  inflammatory  one,  involving  the  greater 
part  of  the  mucous  membrane  of  the  larynx.  That  its  action  is  also 
deeper  than  this,  is  shown  by  the  motile  disturbances  in  the  vocal  cords, 
which  correspond  exactly  with  paralysis  of  the  crico-arytenoidei  postici; 
that  is.  of  the  abduction-fibers  in  the  recurrent  laryngeal  nerve.  But 
such  disturbances  may  be  of  a  purely  mechanical  nature,  produced  by 
any  obstruction  in  or  about  the  joint,  in  this  case  the  crico-arytenoidean 
articulation.  The  latter  theory  is  supported  by  the  diffuse  character  of 
the  inflammation.  We  assume,  then,  an  arthritic  process,  associated 
with  inflammation  of  the  cartilage  or  rather  of  the  matrix.  This  view 
is  further  confirmed  by  the  marked  swelling  and  inflammation  of  the 
aryepiglottidean  fcjlds. 

Without  further  hesitation  we  may,  therefore,  make  the  diagnosis  of 

Crico-arytenoidean  Perichondritis  and  Inflammatory  Ankylosis  of  the 
Crico-ar3rtenoidean  Articulation. 

Tlie  subsequent  course  of  the  case  revealed  the  cause.  After  per- 
forming tracheotomy  and  putting  the  patient  on  an  active  potassium- 
iodid  treatment  we  see  the  following  picture. 

Fig.  3. 

The  swelling  has  disappeared  in  the  entire  larynx,  except  in 
the  posterior  wall.  Over  the  left  cuneiform  cartilage  is  a 
spherical,  grayish-yellow,  glistening  eminence  in  the  mucous 
membrane  (edema),  between  which  and  the  cartilage  of  Wris- 
berg  a  notch  is  seen. 

The  right  vocal  cord  is  white  and  smooth  ;  the  left  is  still 
inflamed  and  somewhat  rough  at  the  edge.  The  glottis  is  per- 
fectly widened  during  respiration.  A  smooth,  red,  horizontal 
band  of  tissue  projects  from  under  the  commissure  and  covers 
half  the  lumen,  ending  behind  in  a  convex  margin.  The  un- 
covered part  of  the  trachea  exhibits  a  bright  luminous  line. 

The  latter  evidently  corresponds  with  the  tracheotomy-tube,  which 
is  still  in  position.  The  band  of  tissue,  on  being  examined  with  a 
sound,  is  found  to  be  smooth,  of  the  hardness  of  cartilage,  and  about  3 
mm.  in  thickness.  Taking  everything  into  consideration  we  may  pro- 
nounce it  a 

Syphilitic  Cicatricial  Diaphragm. 

Our  earlier  supposition,  that  the  impeded  abduction  was  due 
to  an  inflammatory,  ankylotic  condition,  also  proves  correct, 
for  the  mechanical  alterations  disappeared  at  the  same  time 
and  in  the  same  measure  as  the  inflammatory  symptoms; 
remains  of  them  arc  still  found  in  the  edema  over  the  apex  of 
the  left  arytenoid  cartilage  and  in  the  secondary  inflammation 
of  the  corresponding  vocal  cord. 


Tab.  30. 


X        "<•- 


Fuf.l. 


Fig/J. 


LUh.  Anst  F.  Heichiwld,  Miifichen 


Tab    31 


X 


Hio 


r^ 


Fiffi 


fiif.Z. 


t'ig.,i. 


Ulh.  ArLst  /■:  Hfidlholil.  Mulirli 


PLATE   31. 

Fig.  I. 

A  strongly  built  man,  63  years  old,  otherwise  quite  healthy,  has  suf- 
fered for  the  last  two  j^ears  with  disturbance  of  the  voice  and  great 
hoarseness ;  the  symptoms  have  become  more  marked  in  the  past  two 
months.    No  pain,  no  cough.    The  voice  is  rough  and  toneless. 

Larynx. — In  front,  under  the  epiglottis,  the  petiolus  of  which 
it  hides  completely,  is  a  rounded,  somewhat  uneven  tumor,  a 
Uttle  larger  than  a  pea.  The  surface  is  covered  with  red  and 
white  spots.  The  rest  of  the  larynx  presents  no  marked  altera- 
tions, except  that  the  left  vocal  cord  and  the  posterior  margin 
of  the  epiglottis  are  slightly  more  injected.  The  movements 
of  the  true  and  false  vocal  cords  are  unimpaired. 

The  patient's  age  and  the  irregular  appearance  of  the  tumor  lead  us 
to  suspect  a  malignant  growth,  but  the  disease  has  lasted  a  long  time  (at 
least  two  years)  without  invading  the  surrounding  tissues  or  giving  rise 
to  disturbances  of  motility,  so  that  we  are  justified  in  assuming  an 

Innocent  Neoplasm. 

To  be  conscientious,  however,  we  must  make  a  histological  examina- 
tion of  the  extirpated  tumor  (the  result  is  illustrated  on  PI.  34,  Fig.  1) 
and  watch  the  patient  for  some  time  after.     (The  tumor  did  not  recur.) 

Fig.  2. 

A  vigorous  man,  56  years  old,  has  suffered  with  dysphonia  for  ten 
years.     No  other  symptoms  to  complain  of;  no  pain,  no  dyspnea. 

The  voice  is  all  but  aphonic — a  mere  rough  whisper;  i)honation  is 
always  preceded  by  a  long,  audible  inspiration,  and  the  first  expiratory 
sound  is  accompanied  by  a  distant  rattling  sound.  The  larynx  does  not 
move  during  inspiration  and  is  thrown  into  strong  vibration  by  phona- 
tion.  Otherwise  there  is  nothing  abnormal  on  palpation.  The  face  and 
the  mucous  membrane  of  the  back  of  the  mouth  are  highly  colored,  but 
not  cyanotic. 

At  the  first  glance  into  the  larynx  the  entire  interval  be- 
tween the  epiglottis  and  the  posterior  wall  is  seen  to  be  filled  by 
a  mass  which  is  moved  by  the  expiratory  blast ;  the  surface  is 
somewhat  rough,  white  in  front,  more  of  a  reddish  hue  beliind. 
The  parts  which  are  still  visible  (arytenoid  cartilages,  small 
portions  of  the  ventricular  bands  and  of  the  right  vocal  cord) 
do  not  deviate  from  the  norm.  The  mass  is  intimately  adherent 
to  the  anterior  portions  of  the  aperture,  but  its  origin  cannot 
be  made  out  very  clearly. 


The  absence  of  any  signs  of  destruction  at  or  about  the  seat  of  the 
tumor,  its  duration,  and  general  apj)earance  permit  the  diagnosis  of 

Innocent  Tumor. 

Histological  examination  shows  it  to  be  a  hard  fibroma. 


Fig.  3. 

A  woman,  40  years  old,  is  in  imminent  danger  of  asphyxiation.  The 
dyspnea,  which  had  existed  occasionally  in  a  slight  degree,  has  de- 
veloped rapidly  in  the  last  few  hours. 

The  patient  sits  upright,  breathing  slowly  and  painfully,  and  using  all 
the  muscles  of  the  neck ;  a  loud  noise  is  heard  both  in  inspiration  and 
in  expiration.  The  voice  is  rough,  almost  aphonic.  As  soon  as  the 
tongue  is  drawn  forward  a  greenish-yellow,  half-dried  bolus  of  muco-j^us 
is  seen  on  the  posterior  wall  of  the  pharynx,  extending  upward. 

The  entire  entrance  to  the  larynx  is  covered  by  a  thick,  gray- 
ish-green, dry  mass,  the  back  part  of  which,  judging  from  the 
more  uniformly  glistening  appearance,  is  a  little  more  moist. 
It  is  everywhere  raised  above  the  level  of  the  surrounding,  in- 
flamed mucous  membrane. 

This  crust  is  immovable  even  during  phonation. 

Nose  and  fauces  are  filled  with  a  mass  of  liquid  and  solid  pus,  the 
source  of  which  is  found  in  a  diseased  condition  of  the  cribriform  plate 
of  the  ethmoid  bone. 

The  foreign  body  in  the  larynx  is,  therefore,  also  a  crust  of  pus ;  it  is 
simply  an 

Obstruction  by  a  Foreign  Body. 


PLATE   32. 

Fig.  I. 

A  boy,  3i  years  old,  comes  to  be  examined  for  complete  aphonia 
and  intense  dyspnea.  Inspiration  especially  is  labored  and  very  pro- 
longed ;  all  the  accessory  muscles  are  plainly  seen  to  assist  in  the  act, 
which  is  also  accompanied  bj^  loud  stridor.  At  the  same  time  the  larynx 
is  deeply  depressed.  Expiration  is  somewhat  less  difficult.  Face  and 
extremities  are  markedly  cyanotic.  The  condition  developed  in  the  last 
two  years  after  an  attack  of  whooping-cough. 

Laryngoscopy. — The  mucous  membrane  of  the  epiglottis, 
which  is  displaced  forward,  shows  a  faint  bluish-red  discolora- 
tion. Under  the  epiglottis  and  covering  the  entire  aperture  of 
the  larynx  is  a  bright,  brick-red  tumor,  the  surface  of  which 
exactly  resembles  that  of  a  mulberry.  On  palpation  with  the 
finger  the  tumor  is  found  to  be  soft  and  very  slightly  movable. 
It  is  evidently  a 

Papilloma, 

a  form  of  laryngeal  tumor  very  characteristic  of  childhood. 

Fig.  2. 

A  woman,  30  years  old,  complains  of  hoarseness  and  dyspnea.  The 
hoarseness  has  existed  three  or  four  years ;  the  dyspnea  has  increased 
lately.  She  has  lost  strength,  has  night-sweats  and  cough,  but  no  ex- 
pectoration. Her  fatlier  died  of  pulmonary  phthisis.  The  woman  is 
slender  and  delicate ;  she  has  lost  her  voice  entirely,  and  there  is  audible 
laryngeal  stridor  when  she  breathes ;  the  thyroid  cartilage  at  the  same 
time  moves  up  and  down.  Under  the  angle  of  the  jaw  on  each  side  is  a 
gland  as  large  as  a  pigeon's  egg.  There  is  resonance  all  over  the  lungs, 
but  the  right  apex  is  somewhat  depressed ;  under  the  riglit  clavi(.*le 
accentuated,  prolonged  expiration  is  heanl.  Accentuated  breath-sounds 
and  dry  rales  are  heard  all  over  the  lung.  Heart-action  is  weak,  dul- 
ness  .small,  heart-sounds  pure. 

The  larynx  as  a  whole  is  rather  anemic  (as  is  the  mucous 
membrane  of  the  mouth);  the  interior  is  cornpk^tely  filled 
with  slightly  pa[)illary,  raspberry-colored  tumors,  which  grow 
out  from  the  ventri(ailar  l)ands  and  the  posterior  wall,  so  that 
only  the  posterior  third  of  each  vocal  cord  is  visible.  These 
latter  are  rough  and  grayish  in  color.  No  iilceration  is  seen 
anywhere.  The  tumors,  when  touched  with  a  sound,  are  found 
to  be  very  hard. 

The  wide,  diffuse  distribution  and  the  appearance  of  the  tumors, 
together  with  the  general  conditiijn,  permit  a  provisional  diagnosis  of 

Tuberculous  Tumors. 

Diagnosis  confirmed  by  microscopic  examination. 


Flff.l 


Tab.  32. 


tr 


Fiff.  ^. 


Ulh.  Anst  F.  Retchhold.  Miuudhen . 


-^->::^-c^ 


Tab.  33. 


Jig.l.        Vergn^o/i 


'■.^k 


-  -  -  -  :s-------^-Z'i^^W 


G 


~3^?<Ef C'.- - '.' ' 


Lilh.AriM  t:  Keichhold.  Munrhen . 


PLATE   33. 
Fig.  I. 

The  nodules  on  the  true  vocal  cord,  shown  in  Plate  14,  Fig. 
2,  were  removed  and  a  horizontal  section  was  made. 

The  base  consists  of  fairly  dense  connective  tissue,  the  lymph- 
spaces  of  which  are  surrounded  by  slight  accumulations  of 
round  cells.  Some  of  the  vessels  are  much  dilated  and  filled 
with  blood.  On  the  right,  the  tissue  is  filled  with  blood  from  a 
profuse  hemorrhage,  evidently  traumatic  in  origin. 

The  surface  is  formed  by  two  elevations  consisting  chiefly  of 
epithelium,  divided  by  a  deep  vertical  incision.  The  epithe- 
lium exhibits  great  proliferation ;  toward  the  left  a  thick,  club- 
shaped  mass  extends  as  far  as  a  greatly  dilated  vessel,  curved 
like  an  S.  This  mass  is  surrounded  by  a  band  of  round-celled 
infiltration  as  by  a  cordon.     The  superficial  layers  are  horny. 

The  inflammatory  origin  of  the  neoplasm  is  at  once  evident 
from  the  alterations  in  the  vessels ;  the  epithelium  probably 
proliferated  secondarily,  chiefly  in  consequence  of  the  pressure 
from  the  other  vocal  cord  during  phonation. 

The  tumor  is,  therefore,  an 

Inflammatory  Hyperplasia. 

Fig.  2. 

In  its  essential  features  this  preparation  is  similar  to  the  pre- 
ceding. 

The  epithelial  proliferation  is  more  active,  and  has  resulted 
in  the  formation  of  villous  processes  which  tend  to  coalesce. 
The  same  band  of  round-celled  infiltration  appears  along  the 
upper  boundary.  The  grouping  of  the  round-celled  infiltration 
about  the  blood-vessels  is  very  conspicuous,  and  the  cornifica- 
tion  of  the  superficial  layers  has  gone  on  to  the  formation  of 
lamellae.  Like  the  preceding,  this  tumor,  which  grew  like  a 
wart  on  the  posterior  wall  of  the  chronically  inflamed  larynx 
of  a  man,  46  years  old,  is  an 

,  Inflammatory  Fibro-epithelioma. 


Fig.  3. 

The  preparation  is  a  vertical  transverse  section  of  the  tumor 
shown  in  Plate  15,  Fig.  1. 

The  root  of  connective  tissue  almost  disappears  between  the 
two  layers  of  epithelium  which  enclose  it  above  and  below, 


The  upper  layer,  which  corresponds  to  the  httle  whitish  tumor 
seen  macroscopically,  forms  an  enormous  epithelial  mass.  It 
is  chiefly  made  up  of  very  large  polygonous  squamous  cells ; 
at  the  base  some  stratified  squamous  epithelium  is  seen,  while 
the  surface  consists  of  numerous  horizontal  lamellae,  the  original 
epithelial  character  of  which  is  shown  by  the  few  remaining 
nuclei.  The  enormous  thickness  of  this  zone  of  horny  epithe- 
lium explains  the  white  color  of  the  living  tumor. 

The  connective  tissue  is  filled  with  blood  and  presents  numer- 
ous clefts,  due,  no  doubt,  to  edematous  swelling  of  the  tissue, 
which  was  but  poorly  nourished  through  its  slender  pedicle. 

(With  a  higher  power  numerous  elastic  fibers  are  seen  at  "  a," 
representing  proliferations  of  the  media  of  blood-vessels,  show- 
ing that  all  the  tissues  were  involved.) 

Innocent  Homy  Epithelioma. 


PLATE   34. 
Figs.  I  and  2. 

A  sagittal  section  was  made  of  the  tumor  shown  in  Plate  31, 
Fig.  1. 

This  preparation  shows,  even  better  than  any  of  the  preced- 
ing ones,  the  round-celled  infiltration  of  chronic  inflammation 
associated  with  the  highest  degree  of  epithelial  hyperplasia. 
The  villous  j^rocesses  of  the  latter  extend  almost  to  the 
boundary  of  the  healthy  tissue.  The  superficial  laj-ers  present 
a  very  curious  picture  :  the  large  polygonal  cells  with  vesicular 
nuclei  are  replaced  by  a  network,  the  meshes  of  which  corre- 
spond approximately  with  the  cell-areas,  but  contain  only  a  few 
scattered  nuclei.  Instead  of  these,  niunerous  large  masses  of  a 
homogeneous  color  are  scattered  through  the  network,  and  in 
many  places  the  meshes  are  larger  than  the  adjoining  cells. 

This  difference  is  emphasized  in  the  peripheral  portion 
(marked  R),  shown  under  a  higher  power  (Fig.  2).  The  altera- 
tions manifest  themselves  as  extensive  fatty  degeneration  of 
the  epithelium  ;  the  fjit  has  collected  to  form  the  lumps  at  '*a," 
Avhile  at  "b  "  some  cells  are  still  to  be  seen,  though  their  con- 
tents are  disintegrated  and  granular.  This  mixture  of  fatty 
and  of  partially  intact  areas  is  resjjonsible  for  the  peculiar, 
mottled  (macroscopic)  appearance  of  the  surface. 

Inflammatory  Hyperplasia,  with  Epithelial  Degeneration. 

Fig.  3. 

This  illustration  presents  a  similar  form  of  degeneration. 

The  flat,  sui)erficial  growth  (taken  from  the  vocal  cord  of  a 
lady,  42  years  old)  consists  almost  exclusively  of  epithelial  pro- 
liferations, undergoing  degeneration  not  only  at  the  surface,, 
but  clear  through  to  the  bottom.  The  protoplasm  is  on  the 
verge  of  absorption,  as  the  numerous  bright  spaces  in  it  show  ; 
in  places  it  is  swollen,  and  the  nuclei  have  disappeared  for  the 
most  part.  As  in  the  preceding  case,  the  outlines  of  the  cells 
have  remained  substantially  the  same,  instead  of  becoming 
flattened  and  forming  lamellae,  as  in  cornification. 

Epithelial  Hyperplasia  in  Process  of  Degeneration. 


Tab.  34. 


a 


MM 


a 


'^^m^ 


^'0^^^^ 


>«%>^- 


Tiff.l.        Vergr.^04 


*V^% 


^-^::::# 


'I 

Mi 


:3^i     >7: 


a 


.  r© 


z-^.^.  Ver^rr.y 


A^.  J.        Vercjr.  25/i 


Lith.  Anst  F.  RetcMwld,  Miinchen. 


Tab.  35. 


Fig.l.       Vergn^o/i 


I 


Fiff.^.       Vergr.  25/1 


Lilh.Anst  F  ReichhoLd,  MiUiche/i. 


PLATE   35. 
Fig.  I. 

A  dense,  pale-red,  uneven  tumor  was  removed  from  the  left 
ventricular  band  of  a  man  40  years  old. 

In  a  horizontal  section  the  core  of  dense,  fibrous  connective 
tissue  appears  in  the  form  of  an  elevation,  partly  covered  over, 
and  partly  traversed  by  numerous  layers  of  squamous  epi- 
thelium, so  that  several  isolated  islands  of  connective  tissue, 
"  a,"  are  seen  in  its  substance.  These  islands,  as  well  as  other 
areas  near  the  epithelium,  especially  the  portions  surrounding 
the  blood-vessels,  exhibit  profuse  round-celled  infiltration.  The 
surface  is  horny  and  covered  at  "  Bl  "  by  a  thick  layer  of  clotted 
blood,  which  shows  beginning  metamorphosis  into  comiective 
tissue. 

Inflammatory  Hyperplasia. 


Fig.  2. 

The  mulberry-shaped  tumor,  light  pink  in  color,  was  removed 
from  the  left  vocal  cord  of  a  man  50  years  old.  The  cold-wire 
snare  was  used.  The  tumor  had  a  very  narrow,  smooth  pedicle, 
surrounded  on  all  sides  by  wavy  masses  of  proliferated  epi- 
thelium from  the  surface.  A  vertical  section  down  to  the  base 
does  not,  therefore,  include  the  center,  but  only  lateral  portions 
of  the  tumor,  and  is  bounded  on  all  sides  by  epithelium.  The 
real  framework  consists  of  dense,  fibrous  connective  tissue,  con- 
taining dilated  blood-vessels  (G),  the  walls  of  which  are  in  part 
hypertrophied.  On  the  free  surface  the  epithelium  is  arranged 
in  numerous  horizontal  layers,  while  further  down  the  layers 
of  epithelium  occupy  a  plane  at  right  angles  to  that  of  the  base, 
the  transition  between  the  two  directions  being  effected  grad- 
ually. The  similarity  of  the  tissue  to  epidermis  is  unmistak- 
able. The  boundary-line  between  epithelium  and  connective 
tissue  is  fairly  even  in  some  parts,  in  others  it  is  more  or  less 
deeply  indented,  wherever  the  connective  tissue  sends  out  pro- 
jections into  the  epithelial  layer.  On  the  left  there  is  a  very 
extensive  projection  of  this  kind  (B),  enclosed  on  both  sides  by 
a  thick  shell  of  epithelium,  which  in  turn  shows  numerous 
indentations.  Several  large  islands  of  epithelial  tissue  are 
grouped  about  the  surface  of  the  tumor  without  any  apparent 
connection  with  it.  Each  of  these  islands  contains  a  central 
core  of  connective  tissue,  and  many  similar  cores  are  also  seen 
in  the  substance  of   the  thick  epithelial  zone  itself,  showing 


that  it  is  not  a  homogeneous  formation,  but  rather  the  result  of 
fusion  of  contiguous  processes.  The  islands  are,  in  fact,  only 
peninsulas ;  their  isthmuses  are  to  be  found  in  deeper,  or  in 
more  superficial  sections.  The  whole  formation  might  be  com- 
pared to  a  tree  with  a  rich  network  of  interlacing  branches. 

It  is  to  be  noted  that  each  of  the  larger  outgrowths  of  con- 
nective tissue  has  its  own  vascular  supply ;  this  does  not  appear 
everywhere  in  the  picture,  owing  to  the  low  power  used,  but  is 
quite  plainly  seen  at  G. 

Papillary  Fibro- epithelioma. 


PLATE   36. 
Fig.  I. 

This  preparation  was  taken  from  the  epiglottis  of  a  httle  girl, 
9  years  old,  who  died  of  multiple  recurrent  tumors,  resembling 
cauliflower,  in  the  larynx  and  trachea. 

At  the  base  of  the  sagittal  section  the  cut  surfaces  of  the  car- 
tilage are  seen.  Next  is  a  broad  layer  of  loosely  arranged  fibers 
(G),  and  tissue-islands  in  process  of  hyaline  degeneration  (d); 
above  this  is  a  dense  layer  of  connective  tissue,  surrounded  at 
its  upper  boundary  by  round-celled  infiltration.  As  in  the  pre- 
ceding case,  the  epithelial  layer  in  some  places  is  enormously 
hypertrophied  ;  the  boundary-line  between  it  and  the  basal 
tissue  is  marked  by  undulations  and  indentations  correspond- 
ing to  outgrowths  from  the  connective  tissue.  At  certain 
points  we  see  the  evidences  of  connective-tissue  processes 
growing  in  from  different  planes.  But,  whereas  in  the  preced- 
ing case  the  changes  in  outline  were  produced  exclusively  by 
hyperplasia  of  the  basal  tissue — in  other  words  the  growth  was 
chiefly  eccentric  (centrifugal)  in  character — we  here  see,  in 
addition,  an  active  proliferation  of  the  epithelium  itself  at  one 
sj^ot,  resulting  in  the  formation  of  a  process  which  extends 
almost  to  th«  deeper  tissue-layers.  The  epithelial  proliferation 
has,  therefore,  begun  to  absorb  the  normal  tissue,  and  this  gives 
the  growth  a  malignant  character.  We  are  accordingly  justified 
in  pronouncing  it  a 

Destructive  Papillary  Epithelioma. 

The  diagnosis  is  confirmed  when,  under  a  higher  power,  the 
dividing-line  between  epithelium  and  round-celled  infiltration, 
at  the  projections  marked  b,  appears  so  indistinct  that  the  epi- 
thelium may  be  assumed  to  be  migrating  directly  into  the  con- 
nective tissue. 


Fig.  2. 

Four  years  ago  aman,  42  years  old,  had  a  number  of  multiple 
raspberry -like  tumors  removed  from  his  larynx.  Two  years 
afterward  there  was  no  sign  of  recurrence  ;  now,  two  years  after 
the  last  examination,  the  entire  larynx  is  again  filled  with  pale- 
red,  papillary  tumors.  The  preparation  was  taken  from  one 
of  the  vocal  cords  after  death.  It  shows  numerous  projections 
of  connective  tissue  covered  with  a  thin  layer  of  epithelium. 
Some  thicker  strands  of  epithelium  have  even  penetrated  as 
far  as  the  glandular  layer,  displacing  normal  tissue  in  their 


atypical,  eccentric  growth.  Still,  the  general  direction  of  these 
processes  is  more  or  less  parallel  to  the  surface,  so  that  we  can 
hardly  pronounce  the  growth  a  carcinoma  ;  rather,  in  view  of 
the  uniform  proliferation  of  the  surface,  is  it  to  be  regarded  as  a 

Destructive  Papillary  Epithelioma. 

Fig.  3. 

Vertical  transverse  section  of  the  free  border  of  the  vocal 
cord ;  the  upper  portion  is  shown  at  O,  the  lower  at  U.  The 
fibers  are  found  chiefly  in  the  lower  half  of  the  cord,  and  run 
parallel  with  each  other  from  before  backward.  The  prepara- 
tion also  shows  the  appearances  of  chronic  catarrh  in  the  accum- 
ulations of  round-cell  infiltrations  about  the  blood-vessels  G. 


Tab.  36. 


G 


Fig.^.      Vergr.  is/ 


Lith.  Arist  F.  Raidihold.  Miinchen . 


Tab.  37. 


D 


lig.l.       Vergr.16/, 


Ficf.Ji.       Vercjr.  300/^ 


Fiy.'J.       Vergr.  Wi 


LUh.Ansl  F.  Reidihold,  Mdndi 


PLATE    37. 
Figs.  I  and  2. 

This  is  a  section  of  the  tumor  shown  in  PI.  24,  Fig.  3.  Only 
the  central  portion  of  the  surlace  is  covered  with  proliferating 
epithelium  sending  down  numerous  thick  processes;  imme- 
diately beneath  is  a  layer  of  soft  connective  tissue  containing 
dense  areas  of  round-celled  infiltration  and  groups  of  glands 
(D),  wedged  in  between  the  two  lateral  portions.  The  latter 
consist  almost  entirely  of  an  irregular  network  of  epithelioid 
cells  in  chains,  with  here  and  there  a  narrow  strip  of  connective 
tissue — a  tumor  of  alveolar  character. 

The  higher  amplification  in  Fig.  2  reveals  the  nature  of  the 
cells  forming  the  parenchyma  of  the  tumor.  They  resemble 
the  epithelial  elements  found  in  the  pelvis  of  the  kidney,  hav- 
ing irregular  round  bodies  with  sharp  processes.  Some  of  them 
are  multinuclear  and  probably  engaged  in  reproduction.  The 
individual  cells,  however,  are  not  in  immediate  contact  with 
each  other,  being  separated  by  slender  interstitial  fibers  of  con- 
nective tissue,  so  that  even  this  epithelioid  structure  is  really  a 
connective-tissue  formation.  Judging  from  the  situation  and 
appearance  of  the  cells,  we  are  inclined  to  regard  them  as 
degenerated  endothelium  from  the  lymph-spaces.  It  is  there- 
fore an 

Alveolar  Sarcoma. 


Fig.  3. 

At  first  sight,  this  picture  appears  very  similar  to  the  pre- 
ceding :  numerous  large  spherical  and  club-shaped  masses  re- 
sembling epithelium,  separated  by  small  quantities  of  connec- 
tive tissue.  The  part  of  the  surface  on  the  left  is  not  covered 
by  epithelium ;  it  consists  largely  of  naked  connective  tissue, 
lined  on  the  free  edge  by  a  narrow  border  of  densely  packed 
round  cells,  so  closely  simulating  true  epithelium  that  their 
real  nature  is  only  recognized  with  a  very  high  power — a  pseudo- 
epithelium. 

The  cells  of  the  tumor  itself  prove  to  be  true  epithelial  cells 
in  close  contact  with  each  other  (without  any  intervening 
spaces). 

The  tumor,  which  is  seen  macroscopically  in  PI.  27,  Fig.  1,  is 
therefore  a 

Carcinoma. 


PLATE    38. 

Fig.  I. 

A  thick,  smooth  tumor  from  the  left  vocal  process  of  a  man, 
26  years  old.  The  outer  covermg,  which  is  fairly  uniform  in 
thickness,  consists  of  several  layers  of  sciuamous  epithelium ; 
next  comes  a  layer  of  dense  tissue  of  about  the  same  thickness, 
containing  spindle-shaped  cells.  The  interior  consists  of  loose 
connective  tissue  poorly  supplied  with  cells  and  broken  up  into 
large  cavities  with  thin  walls ;  the  latter  are  lined  with  a  single 
layer  of  endothelium  (En),  and  correspond  to  dilated  lymph- 
spaces  or  lymphatic  ducts.  Part  of  the  supporting  tissue  (a), 
even  when  seen  under  a  high  power,  shows  no  nuclei  and 
appears  to  be  made  up  of  structureless  debris ;  it  is,  therefore, 
engaged  in  retrogressive  metamorphosis.  This,  as  well  as  the 
lymph-spaces,  must  be  regarded  as  a  manifestation  of  an  edem- 
atous process.    The  tumor  is  an 

Edematous  Lymphangiofibroma. 

Fig.  2. 

This  smooth,  pale-red  tumor,  from  the  right  vocal  cord  of  an 
elderly  man,  presents  a  similar  formation  on  the  surface  as  well 
as  in  the  deeper  parts.  The  proliferation  of  epithelium  (E) 
toward  the  base  is  more  active  and  shows  the  characteristic 
villous  formation ;  the  cells  are  more  abundant  in  the  body  of 
the  tumor,  and  there  are  large  clefts  not  lined  with  endo- 
thelium. The  latter  are,  therefore,  not  lymph-spaces,  but 
simple  mechanical  dilatations  of  the  tissues  by  edema.  Signs 
of  edema  are  also  seen  at  "0,"  where  the  tissue  is  still  con- 
tinuous, and  of  impaired  nutrition  in  the  form  of  structural 
loss  at  "a." 

As  the  lymph-spaces  themselves  are  but  little  involved,  the 
tumor  is  practically  an 

Edematous  Fibroma. 


Fig.  2. 

The  accompanying  cut  represents  a  part  of  the  epithelial 
covering  of  the  above  preparation.  The  upper  half  is  engaged 
in  complete  metamorphosis.  The  cells,  which  are  quite  small 
in  the  deeper  layers,  gradually  increase  in  size,  and  their  pro- 
toplasm becomes  more  and  more  granular  as  they  approach 


the  surface.  At  last  the  cell-boundaries  are  lost  entirely,  the 
nuclei  disappear,  and  only  a  few  "  shadow "  cells  are  dis- 
tinguishable.   The  latter  are  enlarged  to  forty-five  times  their 


m 


Fig.  24. 


normal  size  and  completely  filled  with  granular  material.  The 
whole  is  covered  by  several  layers  of  dense  lamellae  without 
nuclei— the  results  of  cornification. 


Tab.  38. 


Tiff.l.       Vergr.  ^fi 


S^^^mS 


•r^^;'\k 


^^u^  'fy 


o  & 

Fig.  2.        Vergr.  25/i 


lUh.  Anst  F.  Retchhold,  Mdnjchen. 


Tab. 


'A( 


/vv/..y.      Vercjr.  ^f/ 


c 

Lilh:  Arts  I  F.  Retdihold,  Mmidijen . 


PLATE    39. 
Fig.  I. 

This  preparation  is  a  sagittal  section  of  one  of  the  two  small 
symmetrical  tumors  shown  in  PI.  15,  Fig.  2.  The  growth  con- 
sists of  a  hollow  sac  filled  with  a  clear  mucoid  substance;  the 
cavity  occupies  almost  the  entire  body  of  the  tumor  and 
merges,  without  any  clearly  defined  line  of  demarcation,  into  a 
delicate  connective  tissue  moderately  rich  in  cells  and  thick 
blood-vessels.  The  whole  is  covered  by  a  layer  of  squamous 
epithelium  of  varying  thickness,  which  sends  down  villous 
Xjrocesses  here  and  there  toward  the  center  of  the  tumor.  The 
cavity  is  evidently  due  to  loss  of  substance.  In  order  to  get  a 
clearer  understanding  of  the  way  in  which  this  cavity  was 
formed  let  us  compare  it  with  Fig.  25. 


Fig.  25. 


The  interior  of  this  preparation  is  almost  homogeneous,  with 
only  a  few  groups  of  round  cells  scattered  here  and  there ;  if 
we  imagine  this  area  to  have  undergone  the  same  degenera- 
tion (by  colliquation  and  absorption  of  the  broken-down  cells) 
that  is  seen  in  the  first  preparation,  we  shall  obtain  an  almost 
exactly  similar  picture,  the  only  difference  being  the  narrow 
peripheral  zone  of  denser  connective  tissue.     It  is  therefore  an 

Absorption-cyst  within  a  Soft  Fibroma. 


PLATE  40. 
Fig.  I. 

This  cut  also  exhibits  marked  changes  in  the  blood-vessels, 
although  somewhat  different  in  character  from  the  preceding. 
It  is  taken  from  the  tumor  shown  in  PI.  27,  Fig.  2. 

The  hyperplastic,  horny  epithelial  covering  encloses  a  core 
of  connective  tissue  filled  with  numerous  dilated  lymph-spaces, 
in  accord  with  the  gelatinous  nature  of  the  edematous  infiltra- 
tion described  macroscopically.  There  is  only  a  very  light 
sprinkling  of  cells.  On  the  right  is  seen  a  rich  network  of 
small  arteries  with  hypertrophied  and  thickly  infiltrated  w^alls, 
but  without  dilatation.  The  condition  is,  therefore,  not  an 
inflammatory,  but  a  purely  hyperplastic  one.  The  concentric 
mode  of  the  hypertrophy  has  led  to  obliteration  of  the  lumen 
in  many  situations,  and  hence,  by  stasis,  to  edema.  We  have 
before  us,  therefore,  an 

Edematous  Angiofibroma. 

Fig.  2. 

Again  the  most  striking  feature,  after  the  enormous  prolifera- 
tion of  squamous  epithelium,  is  the  diseased  condition  of  the 
blood-vessels.  The  section  corresponds  to  the  excrescence  on 
the  posterior  wall  of  the  larynx  shown  in  PL  5,  Fig.  1.  Numer- 
ous small  lumina  of  blood-vessels,  some  of  them  dilated,  are 
seen  at  G.  Some  present  only  a  slight  uniform  hypertrophy 
of  the  media,  while  others  are  surrounded  by  huge  masses  of 
round  cells.  In  places  the  round  cells  have  even  filled  up  the 
lumen,  and  in  the  upper  right-hand  portion  they  are  on  the 
point  of  attacking  the  epithelium.  This  is  not  a  simple  inflam- 
mation of  the  vessel-walls ;  the  uniform  character  of  the  densely 
packed  cells  imbedded  in  loose  areolar  tissue  (as  seen  with  a 
higher  power),  and  disposed  in  spherical  masses,  characterizes 
the  process  even  macroscopically  as 

Syphilitic  Meso-  and  Peri- arteritis,  changing  to  Gumma-formation. 


Tab.  40. 


■•^• 


'l^§^(ii 


f^>--:m 


W 


/Mk 


■^m 


Bl 


Fig.l.      Vergn^o/i 


^^f'- 


i^^y.^.        Vergn  Wi 


Lith.  Arist  F.  ReicMwld,  Munchen. 


Tab.  41. 


a 


Fig.l.      Vergr.^^i 


c 

a 


Fig.^.       Vergr.  25/i 


LUh-Anst  F.  ReiJChhoUl.Munjchjen. 


PLATE   41. 

Fig.  I. 

One  of  the  convolutions  on  the  posterior  wall,  represented  in 
PL  5,  Fig.  3,  was  removed  with  the  galvanocautery ;  it  was 
found  to  be  exceedingly  hard.  In  horizontal  section  the 
growth  appears  as  a  roundish  elevation  of  connective  tissue 
covered  by  an  epithelial  layer  of  varying  thickness.  ^  At  certain 
points  the  epithelium  is  very  abundant  and,  especially  on  the 
left  side,  sends  down  long  ramifications  into  the  basal  tissue. 
That  the  proliferation  proceeds  downward  is  also  proved  by 
the  smooth  outline  of  the  free  surface.  Here  and  there  we  see 
open  spaces  which  probably  correspond  to  the  transverse  sec- 
tions of  invaginated  portions  of  the  epithelial  layer.  The 
central  portion  of  the  base  is  occupied  by  numerous  glands, 
some  of  which  exhibit  considerable  uniform  enlargement, 
while  in  others  the  hypertrophy  of  the  walls  betrays  itself  in 
the  irregular  outline  of  the  transverse  section.  A  zone  of 
round-celled  infiltration  of  varying  density  surrounds  this  area 
of  gland- tissue  and  the  blood-vessels  which  are  seen  at  G.  In 
some  of  the  latter  the  lumen  is  considerably  narrowed  from 
hypertrophy  of  the  inner  wall,  which  at  one  point  (a)  forms  a 
mushroom-like  elevation ;  this  pronounced  form  of  hyperplastic 
endarteritis,  as  well  as  the  peri-arteritis,  accords  perfectly  with 
the  syphilitic  nature  of  the  tumor.  It  does  not,  however, 
possess  any  distinctive  syphilitic  features ;  it  is  a  general  hyper- 
plasia of  all  the  elements  composing  the  mucous  membrane, 
without  any  typical  characters,  so  that  the  tumor  cannot  be 
regarded  as  syphilitic.     It  is  simply  a 

Postsyphilitic  Inflammatory  Hyperplasia. 

The  probable  cause  of  the  growth  has  already  been  discussed 
in  connection  with  PI.  5. 

Fig.  2. 

This  preparation  is  taken  from  PI.  18,  Fig.  3 ;  it  is  a  vertical, 
transverse  section  of  the  tumor  on  the  ventricular  band.  At 
first  sight,  it  seems  to  be  a  hard  wart,  for  we  observe  a  very 
heavy  epithelial  covering,  the  upper  layers  of  which,  being  flat 
and  showing  no  nuclear  stain,  have,  therefore,  become  horny. 
On  the  right  the  epithelium  is  seen  to  dip  down  into  the  basal 
tissue.  The  core  of  the  tumor,  however,  is  anything  but  nor- 
mal :  there  are  three  distinct  areas  of  infiltration,  a  small  one 
in  the  lower  right-hand  portion  (b),  and  two  larger  adjoining 


groups  (c,  d),  which  occupy  almost  the  whole  of  the  center  and 
are  in  turn  made  up  of  smaller,  round  aggregations  of  cells, 
lighter  at  the  center  than  at  the  periphery,  where  the  cells 
are  massed  in  heavier  layers.  In  addition,  we  see  a  dense  in- 
filtration along  the  course  of  small  blood-vessels — a  sign  of  peri- 
arteritis. 

With  a  higher  power  we  note  that  the  round  cells  are  fairly 
uniform  in  size  and  disposed  in  groups  of  varying  density,  but 
no  giant-cells  can  be  made  out.  The  cells  are  imbedded  in  a 
delicate  areolar  stroma ;  at  the  center  of  the  large  group  on  the 
left  they  appear  more  scattered  and  are  not  stained  so  deeply. 

We  know  from  the  anamnesis  that  syphilis  is  present;  but 
the  histological  appearances  alone  would  suffice  for  the  diag- 
nosis.    They  are 

Confluent  Gummata  in  the  Deeper  Tissues,  witli  Hyperplasia  of  the 

Superficial  Elements. 


PLATE   42. 
Fig.  I. 

This  is  a  vertical  section  of  the  ulcer  on  the  epiglottis  shown 
in  PL  5,  Fig.  1. 

The  dense  ground-tissue  (G)  shows  numerous  sclerotic  arte- 
ries ;  overlying  this  is  a  layer  of  tubular  glands  (D),  the  most 
superficial  of  which  are  already  being  absorbed  by  numerous 
small  masses  of  round  cells.  The  latter  are  in  direct  relation 
with  the  free  surface,  the  epitheUum  being  entirely  lost ;  hence 
the  ulceration  extends  almost  to  the  glandular  tissue.  The 
uniform  (areolar)  infiltration  is  of  a  gummatous  nature;  we 
have  before  us  a 

Syphilitic  Ulcer. 


Fig.  2. 

A  horizontal  section  of  the  larynx  taken  from  a  tuberculous 
subject;  only  a  slight  fold  had  been  visible  on  the  anterior  sur- 
face of  the  posterior  wall.  The  section  shows  even  in  this  slight 
alteration  the  signs  of  beginning  infection.  KK,  the  arytenoid 
cartilages  in  transverse  section;  M,  muscle-bundles;  D,  glands. 
Exactly  in  the  centre  (E)  the  epithelium  is  much  hypertro- 
phied  and  forms  a  small  wart-like  elevation  which  corresponds 
to  the  ominous  interarytenoidal  spur  seen  macroscopically. 
Immediately  beneath  we  see  small  aggregations  of  round  cells 
(T),  which  under  a  higher  power  reveal  themselves  as  a  true 
tuberculous  infiltration.  The  (reactive)  epithelial  proliferation 
extends  some  distance  laterally  over  the  surface. 


Tab.  42. 


Lith.  Anst  F.  ReiMwld,  Miindim. 


Tab.  43. 


Fig.l.       Vergr.n/i 


rfSX:? 


Ti      . 


^2s^Sf' 


^K'%^^ 


c^ 


:^- 


D 


fs. 


Fig.^.       Vergp.  104 


LUh.Anst  P  ReicMwld,  Miinchen. 


/' 


PLATE  43. 
Fig.  I. 

This  preparation  was  removed  with  a  curet  from  a  tubercu- 
lous infiltration  on  the  posterior  wall  of  the  larynx. 

The  figure  shows  principally  a  conglomeration  of  tuberculous 
proliferations  merging  into  one  another.  These  overlie  a  cen- 
tral mass  of  dense  connective  tissue  (in  the  lower  left-hand 
portion)  which  forms  the  boundary  of  the  cut  surface,  showing 
that  it  was  made  within  the  limits  of  healthy  tissue.  (The 
yellow  portions  are  not  tissue,  but  portions  of  the  imbedding- 
material.) 

Fig.  2. 

A  horizontal  section  of  the  larjTix  of  a  tuberculous  cadaver 
which  showed  prominent,  pale,  rigid  infiltration  of  the  posterior 
wall. 

We  see  two  large  areas  of  infiltration  separated  by  a  deep 
fissure,  lined  with  a  thin  layer  of  epithelium.  At  the  bottom 
of  the  fissure  the  infiltration  has  invaded  the  epithelium  and  in 
part  crowded  it  out  entirely,  so  that  it  appears  completely 
naked.  The  infiltration  possesses  a  pronounced  tuberculous 
character,  even  under  the  low  power.  The  cells  exhibit  a 
circular  arrangement  with  a  lighter  area  in  the  center,  poor  in 
nuclei,  showing  that  degeneration  has  begun.  Even  the  peri- 
chondrium of  the  upper  cross-section  of  the  (left)  arytenoid 
cartilage  shows  infiltration. 

The  (non-specific)  reaction  manifests  itself  in  this  case  not  in 
the  epithelium,  but  in  the  vessels,  whose  w^alls  are  much  hyper- 
trophied  :  the  beginning  of  sclerosis  so  common  in  tuberculosis. 


PLATE  44. 
Fig.  I. 

A  section  of  a  club-shaped  tumor  on  the  left  ventricular  band 
of  a  man  44  years  old.  Macroscopically  the  tumor  presented  the 
appearance  of  a  pale,  uneven  papilloma,  about  f  cm.  in  length, 
6  mm.  in  breadth,  and  ^  cm.  in  thickness.  Three  other  similar 
tumors  were  seated  in  the  same  situation.  The  remaining 
parts  of  the  larynx  and  the  lungs  were  normal.  The  epithelium 
(E)  presents  numerous  villous  processes  which  descend  quite 
deeply  into  the  basal  tissue.  Just  as  in  true  papillary  tumors, 
we  see  a  part  of  the  growth  diverging  from  the  main  body  to 
such  an  extent  that  in  transverse  section  it  appears  as  an 
isolated  mass  (Fig.  1^).  But  whereas  such  isolated  portions 
usually  consist  entirely  of  epithelium,  wdth  only  a  slender 
pedicle  (PI.  30,  Fig.  2),  in  this  case  the  external  epithelial  layer 
is  very  thin  and  encloses  an  ovoid  kernel  consisting  chiefly  of 
round  cells  with  only  a  narrow  ring  of  connective  tissue  (T). 
Many  such  masses  or  kernels  are  seen  in  the  tumor  itself,  the 
cells  being  more  densely  packed  near  the  peripher}'  than  at  the 
center. 

With  a  higher  power  we  find  that  the  center  contains  also 
epithelioid  and  giant-cells,  revealing  the  true  nature  of  the 
growth.     It  is  a 

Papillary  Tuberculous  Tumor. 

Fig.  2. 

This  preparation  corresponds  to  the  tumor  shown  in  PI.  32, 

Fig.  2.  The  general  appearance  is  that  of  a  connective-tissue 
growth  with  al)undant  round-celled  infiltration.  The  surface  is 
enclosed  in  a  cellular  band  of  varying  thickness,  which  imder  a 
higher  power  is  also  found  to  consist  of  round  cells — another 
example  of  pseudo-epithelium  (P)  (see  PI.  37,  Fig.  3).  In  the 
center  the  infiltration  al)Out  the  vessels  varies  much  in  density, 
without,  however,  forming  typical  tubercles.  Only  at  one  spot 
on  the  surface  is  there  anything  approaching  in  appearance  a 
tubercle.     We  must  call  the  tumor  a 

Diffuse  Tuberculous  Hyperplasia. 


Tab.  44. 


T.: 


T 


Fig1 


E^.V 


Fig. 


? 


Vergr. 


i5A 


I'.'r 


G 


LWx.Anst  F.  Rei£hJtwld,Mimjdmv. 


Fig.  15, 

A  woman,  43  years  old,  seeks  relief  for  increasing  dyspnea  and  diffi- 
culty in  swallowing.  The  cyanosis  of  the  face  is  very  striking,  and 
there  is  rough,  audible  stridor  in  inspiration.  The  voice  is  rough  and 
sometimes  aphonic. 

The  larynx  is  entirely  concealed  by  a  dark-red  tumor  as  large 
as  a  walnut,  with  a  slightly  wavy  surface  traversed  by  a  few 
large  vessels.  The  tumor  is  free  behind  and  on  the  left  side, 
while  on  the  right  it  is  continuous  with  the  lateral  wall  of  the 
pharynx.  In  front  nothing  is  visible  but  the  epiglottis  and  the 
commissure. 

A  slight  goiter  is  noticeable  on  the  outside  of  the  throat.  On  palpa- 
tion the  right  lobe  is  found  to  extend  more  deeply  than  the  left.  Press- 
ure on  this  part  causes  the  internal  tumor  to  move  slightly  toward  the 
left.  On  bimanual  palpation  (right  index  finger  on  the  tumor  inside, 
left  hand  on  the  goiter  outside)  the  effect  of  pressure  on  one  side  is  even 
more  plainly  felt.    The  tumor  is,  therefore,  beyond  doubt  a 

Struma  Retropharyngea  Dextra. 


Fig.  i6. 

A  young  lady,  23  years  old,  has  lost  her  voice  entirely ;  she  cannot 
speak  above  a  whisper,  l)ut  from  time  to  time  slie  coughs  loudly.  This 
condition  has  lasted  two  weeks;  at  the  same  time  she  complains  of 
violent  pain  in  the  region  of  the  right  cornu  of  the  hyoid  bone.  The 
larynx  as  a  whole  is  rather  pale. 

During  respiration  the  vocal  cords  exhibit  a  slight  twitching  move- 
ment toward  the  middle  line. 

When  the  patient  tries  to  phonate  the  vocal  cords  approach 
only  to  the  cadaveric  position. 

Occasionally,  however,  w^hen  she  coughs,  the  arytenoid  cartilages  are 
seen  to  move  more  distinctly  inward. 

The  fact  that  the  closers  of  the  glottis  are  insufficient  when  a  volun- 
tary attempt  at  innervation  is  made,  yet  respond  to  an  involuntary  act 
of  "the  same  character  (loud  cough),  and  the  absence  of  inflammatory 
signs,  at  once  establish  the  diagnosis  as 

Hysterical  Aphonia. 

Later  it  appears  that  the  hysteria  was  caused  by  a  great  psychical  ex- 
citement. 


Fig.  17. 

A  woman,  40  years  old,  has  been  hoarse  since  she  was  operated  on  Tor 
struma. 

The  right  vocal  cord  is  widely  abducted  during  respiration, 
the  left  remains  midway  between  respiration  and  phonation- 
posture.  The  left  arytenoid  region  is  thrust  somewhat  farther 
forward  than  the  right.  During  phonation  (dotted  lines)  the 
right  cord  moves  to  the  middle  line,  while  the  left  is  immova- 
ble. The  cartilages  on  the  right  side  move  forward  and  inward, 
as  usual ;  those  on  the  left  also,  but  not  to  the  same  extent ;  at 
the  same  time  the  left  aryteno-epiglottidean  ligament  is  slightly 
put  on  the  stretch. 

From  the  anamnesis  and  from  the  absence  of  any  mechanical  obstacle 
we  must  diagnosticate 

Traumatic    Paralysis   of  the    Left   Recurrent   Nerve,  with    Marked 
Vicarious  Function  of  the  Transverse  Ar3rtenoid  Muscle. 


Fig.  i8. 

In  another  patient  the  right  vocal  cord  is  also  fixed  in  the 
cadaveric  position  both  in  respiration  and  in  phonation.  In 
respiration  (a)  the  right  arytenoid  cartilage  stands  a  little  farther 
toward  the  front  than  the  left,  while  in  phonation  (b)  the  oppo- 
site occurs. 

It  is  another  case  of 

Paralysis  of  the  Right  Recurrent, 
but  without  function  of  the  arytsenoideus  transversus. 


Fig.  19. 

In  a  third  case  of  this  kind  the  paralyzed  left  vocal  cord  and 
its  cartilage  are  immovable  during  phonation.  The  right  ary- 
tenoid cartilage,  however,  passes  underneath  the  left;  the  right 
vocal  cord  moves  farther  over,  and  almost  perfect  closure  of  the 
glottis  is  efltected  during  j^honation.  The  voice  is  accordingly 
good,  only  a  slight  hoarseness  being  noticeable. 


Fig.  20. 

A  male  singer,  23  years  old,  suddenly  lost  his  voice  eight  months  ago. 
It  gradually  returned,  but  since  that  time  he  occasionally  becomes 
almost  aphonic  for  one  or  two  days  at  a  time.  During  the  intervals 
between  the  attacks  he  is  able  to  sing  well  and  loud. 

Both  vocal  cords  are  grayish-yellow  and  somewhat  succulent. 

Both  vocal  C'ord.s  move  during  phonation.but  the  right  moves 
so  far  V)eyond  the  middle  line  that  the  left  does  not  get  beyond 
the  cadaveric  position.  At  tlie  same  time  the  right  arytenoid 
cartilage  comes  in  front  of  the  left. 

During  respiration  both  vocal  cords  are  perfectly  abducted.  This 
irregularity,  which  formerly  was.  without  good  reason,  designated  by  the 
special  name  of  asjfinmetrm  arytxnoidea  cruciata,  is  very  suggestive  of 
the  posture  seen  in  paralysis  of  the  recurrent.  In  view  of  the  anamnesis, 
it  may  be  regarded  as  the 

Remnant  of  an  Old  Paralysis  of  the  Left  Recurrent. 


Fig.  21. 

A  woman,  36  years  old.  has  had  dyspnea  for  years;  it  has  been 
gradually  getting  worse,  and  in  the  last  few  days  suddenly  became  in- 
tense. The  cause  is  a  goiter,  not  very  extensive,  but  easily  felt  on  deep 
palpation  ;  it  is  on  the  left  side  of  the  throat. 

With  the  laryngoscope  the  trachea  is  seen  to  be  pushed  to  one  side. 

In  the  larynx  the  position  of  the  left  vocal  cord  is  striking. 
During  phonation  it  stands  exactly  in  the  middle  line,  and 
during  respiration  it  maintains  the  same  position,  only  the  free 
edge,  which  was  stretched  taut  before,  becomes  slightly  concave. 

It  is  the  typical  position  of 

Paralysis  of  the  Left  Posterior  Arytenoid  Muscle. 

As  usual,  it  represents  the  first  stage  of  pressure-paralysis  of  the  left 
recurrent  by  the  struma. 


Fig.  22. 

A  man,  45  years  old,  who  is  found  to  have  been  suffering  with  tabes 
dorsaHs  for  three  or  four  years,  began  to  be  troubled  with  dyspnea  about 
a  week  ago,  so  that  any  active  exercise  has  Ijecome  impossible.  The 
voice  is  loud  and  has  a  good  tone. 

Instead  of  separating,  the  vocal  cords  remain  immovable 
during  respiration,  at  a  short  distance  from  the  middle  line. 

As  there  is  nothing  to  indicate  a  mechanical  obstacle  to  abduction  of 
the  cords,  it  must  be  that  the  abductor  nuiscles  are  paralyzed. 

Tabetic  Paralysis  of  the  Posterior  Crico- arytenoid  Muscles. 


Fig.  23. 

A  -woman,  63  years  old,  has  been  hoarse  for  some  time.  The  voice  is 
feeble,  rough,  and  toneless. 

The  only  abnormality  in  the  larjTix  is  observed  during  phona- 
tion,  which  presents  the  following  curious  picture.  The  edges 
of  the  vocal  cords  present  in  the  resting  position,  as  usual,  a 
smooth,  slightly  concave  outline ;  but  as  soon  as  the  glottis  is 
closed  the  edges  become  wavy,  so  that  closure  is  not  complete. 

A  soimd  can  be  introduced  without  causing  the  patient  to  cough  ;  in 
fact,  she  does  not  feel  it  when  she  closes  her  eyes.  Even  the  tinger 
elicits  no  reflex  either  from  the  epiglottis  or  from  the  superior  aperture 
of  tlie  larynx. 

If  the  finger  is  held  on  the  cricothyroid  ligament  during  phonation, 
no  tension  or  movement  of  the  two  arytenoid  cartilages  can  be  felt.  AVe, 
therefore,,  have  to  deal  with  paralysis  of  the  cricothyroid  muscle  and  of 
the  sensory  nerves  of  the  larynx. 

As  these  constitute  the  entire  domain  of  the  superior  laryngeal  nerves, 
we  have  before  us  a 

Paralysis  of  the  Superior  Laryngeal  Nerves. 

As  no  other  abnormal  condition  can  be  found  in  the  body,  it  is  im- 
possible to  determine  the  cause. 


INDEX. 


(Fig.  indicates  Figure;  PI.  indicates  Plate.) 


AxGiOFiBEOMA,  PI.  39,  Fig.  3 ;   PL 

40,  Fig.  1 
Angioma,   PL   21,  Fig.   3;    PL   39, 

Fig.  2 
Aphonia,  hysterical.  Fig.  16 

Caecixoma,  PL  14,  Fig.  3;  PL  27, 
Fig.  1 ;  PL  28,  Figs.  1  and 
2  ;  PL  29 ;  PI.  37,  Fig.  3 

Cartilages  of  larynx,  9,  10 

Catarrh,  PL  9,  Fig.  1;  PL  11,  Fig. 
1;  PL  14,  Fig.  1;  PL  36, 
Fig.  3 

Cauterization,  33 

Chondritis,  PL  20 

Cortical  center  for  movements  of 
larynx,  19 

Crepitation,  26 

Croup,  pseudo-,  38 

Cyst,  absorption,  PL  39,  Fig.  1 

Diphtheria,  39 

Edema,  acute  inflammatory,  PL  7, 

Fig.  1 ;  PL  26,  Fig.  1 
Electrolysis,  .33 
Epiglottis,  10 

n  shape,  21,  PL  2,  Fig.  1 
Epithelioma,  PL  36,  Figs.  1  and  2 
Epithelium,  distribution  of,  18 
Erysipelas,  PL  25,  Fig.  1 


Falsetto  voice  production,  22 
Fibro-epithelioma,   PL  33,   Fig.  2 ; 

PL  35,  Fig.  2 ;  PL  45,  Fig.  2 
Fibroma.  PL  15,  Fig.  2 ;  PL  18,  Fig. 

2;   PL  38,  Fig.  2;    PL  39, 

Fig.  1 
Foreign-body  stenosis,  PL  31,  Fig.  3 

Galvanocautery,  34 

Herpes,  57,  PI.  6,  Fig.  1 
Hyperplasia,  connective-tissue,  PI. 
14,  Fig.  1 

epithelial,  PL  34,  Fig.  3 

inflammatory,  PI.  10,  Fig.  1 ;   PL 

22,  Fig.  3;  PL  33,  Fig.  1; 
PL  35,  Fig.  1 

pachydermatous,  PL  16,  Fig.  1 
post-syphilitic,  PL  41,  Fig.  1 
tuberculous,  PL  21,  Fig.  2;    PI. 

23,  Fig.  1 ;  PL  44.  Fig.  2 
Hysterical  aphonia,  Fig.  16 

Ixflammatiox,  PL  19,  Fig.  1 
Influenza,  laryngitis  in,  56 
Innervation  of  larynx,  18 

false,  27 
Intubation,  35 


Killian's    posture, 
Fig.l 


22,    PI.    1, 


INDEX. 


Kirsteiu's  method  of  direct  laryu- 
goscopy,  24,  29 

Laryngitis,  acute,  PI.  19,  Fig,  2 
secondary  chrouic,  PI.  10,  Fig.  1 
Ligaments  of  larynx,  10,  11 
Light  in  laryngoscopy,  24 
Lordosis  of  cervical  vertebrge,  PI.  2, 

Fig.  3 
Lymphangiofibroma,  PI.  38,  Fig.  1 
Lymph-follicles,  distinguished  from 
miliary  tubercles,  17 

Maceeation     by     pus,      PI.     10, 

Fig.  2 
Measles,  laryngitis  in,  54 
Muscles  of  larynx,  extrinsic,  10 

intrinsic,  12  et  seq. 
Muscular  process,  12 

Papilloma,  PI.  32,  Fig.  1 
Perichondritis,     syphilitic,    PI.    5, 
Fig.  3 ;  PI.  24.  Fig.  1 
tuberculous.   29,   PI.   17,   Fig.  1; 
PI.  20 
after  typhoid,  PI.  17,  Fig.  2 
Phlegmon,  PI.  7,  Fig.  2 
Phonation,  22 

false     vocal     cord,     23,     PI.    3, 
Fig.  2 
Process,  muscular,  12,  15 
vocal,  12,  15 

Rheumatism,  59 

Sabcoma,  alveolar,  pi.  24,  Figs.  2 
and  3;  Pl.  .37,  Figs.  1  and  2 
Scarlet  fever,  laryngitis  in,  55 
Sinuses,  pyriform,  11 
Small-pox,  laryngitis  in,  .55 
Stenosis,   by  foreign  body,  PI.  31, 

Fig.  3 
Stridor,  27 


Struma,  Fig.  15 
Syphilis,  catarrh,  PI.  14,  Fig.  1 
gumma,  PI.  4,  Fig.  1 ;  PI.  5,  Fig. 
1;    PI.  13,  Fig.  1;   PI.  22, 
Fig.  2 ;   PI.  40,  Fig.  2 ;   PI. 
41,  Fig.  2 
membrane,  PI.  30,  Fig.  3 
meso-   and  peri  arteritis,  PI.  40, 

Fig.  2 
papules,  PI.  11,   Fig.  2;    PI.   12. 

Fig.  1 
perichondritis,  PL  5,  Fig.  3;  Pi. 

24,  Fig.  1 
tertiary,   PI.   5,    Fig.   2;    PI.   21, 
Fig.  1 
depositions,  PI.  18,  Fig.  3 
infiltrate,  PI.  23,  Fig.  2 
ulcers,  PI.  13,  Fig.  3  ;  PI.  42 

Tuberculosis  in  fibro-epithelioma, 

PI.  45,  Fig.  2 
hyperplastic,  PI.  21,  Figs.  1  and 

2;    PI.  23,  Fig.  1:    PI.  44, 

Fig.  2 
infiltrative,  PI.  5,  Fig.  1;   PI.  6 

Fig.  2;    PI.  9,  Fig.  2;   PI 

12,  Fig.  2 ;    PI.  16,  Fig.  2 

PI.  19,  Fig.  3;   PI.  22,  Fig 

1;    PI.  25,   Fig-s.  2  and  3 

PI.  26,  Fig.  2 ;  PI.  43,  Figs. 

1  and  2 
lupous  form,  PI.  4,  Fig.  2 
perichondritis,  PI.  17,  Fig.  1 ;  PI. 

29 
tumors,  PI.  22.   Fig.   1;    PI.  31, 

Fig.  2  ;   PI.  44,  Fig.  1 ;  PI. 

4.5,  Fig.  1 
ulcerative,  PI.  16,  Fig.  2 
Tumors,  benign,  PI.  14,  Fig.  2 ;  PI. 

16,  Fig.  1;    PI.  27,  Fig.  2; 

PI.  31,  Figs.  1  and  2;   PI. 

33,  Fig.  3 
tuberculous,  see  Tuberculosis, 


INDEX. 


Typhoid  fever,  laryngitis  in,  56 

Ventricle  of  Morgagni,  prolapse 

of,  PI.  18,  Fig.  1 
Ventricular  bands,  14 
Ventriloquy,  23 
Vocal  cords,  13 
color  of,  21 
position  of,  in  cadaver,  PI.  13, 

Fig.  2;  PL  17,  Fig.  2;  PI. 

23,   Fig.  2 ;  PI.  25,  Fig.  1 ; 

Figs.  16, 18,  22 


Vocal  cords,  position  of,  in  phuna 
tion,  22 
in  respiration,  PI.  3,  Fig.  1 
paralyses.  Figs.  16  to  23;    PI.  8; 

PI.  13,  Fig.  2 
IH'ocess,  12 
Voice,  character  of,  27 
production,  13,  22 

Wart,  hard,  PI.  15,  Fig.  1 
Whooping-cough,  57 


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